Child Asthma Review form

Name *

Date of Birth *

How is your asthma today? *

(0) Very bad

(1) Bad

(2) Good

(3) Very Good

Does your asthma bother you when you run or play sports? *

(0) Yes, it stops me from what I want to do

(1) It does bother me, I don't like it

(2) A little bit, but it's okay

(3) Not at all

Do you cough because of your asthma? *

(0) Yes, all of the time

(1) Yes, a lot of the time

(2) Just sometimes

(3) No, I don't cough

Do you wake up during the night because of your asthma? *

(0) Yes, all the time

(1) Yes, a lot

(2) Sometimes

(3) No, my asthma doesn't wake me up

During the last 4 weeks, how many days did your child have asthma symptoms during the day? *

(0) Every Day

(1) 19-24 days

(2) 11-18 days

(3) 4-10 days

(4) 1-3 days

(5) Not at all

During the last 4 weeks, how many days did your child wheeze during the day? *

(0) Every Day

(1) 19-24 days

(2) 11-18 days

(3) 4-10 days

(4) 1-3 days

(5) Not at all

During the last 4 weeks, how many days did your child wake up during the night due to their asthma? *

(0) Every Day

(1) 19-24 days

(2) 11-18 days

(3) 4-10 days

(4) 1-3 days

(5) Not at all

Asthma Score *

15 or less = Your child's asthma has not been controlled recently. Please book an appointment for an asthma review

16-19 = Your child's asthma has not been as well controlled as it could be. Please consider booking a review appointment to see how we can help.

20-25 = Your child's asthma is on target and is well controlled.

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Child Asthma Review form

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