Child – Online Asthma Review

Child – Online Asthma Review Questionnaire

Non-urgent advice: Welcome

Welcome to our Online Asthma Review Questionnaire for children.

This questionnaire is for your children aged 16 or younger with a diagnosis of Asthma.

The purpose of this questionnaire is to review your child’s asthma symptoms and control.

Child Asthma Annual Review Questionnaire

About your Child

In this section, we will ask your details about your child

Current Health Status

In this section we will ask you general questions about your child’s general health.
Please select one of the following with regards to your child's smoking status.
If they currently smoke, are they interested in trying to quit or reduce your smoking?
For example – 12st3 or 78kg
For example – 6ft or 1.82m

Asthma Control History

In this section we will ask you questions regarding the recent history of your child’s asthma.
How compliant are they with their inhaler or how would you rate their inhaler technique?

Asthma Control Questions – To be answered by Parent and Child

How is their asthma today?
How much of a problem is their asthma when they run, exercise or play sports?
Do they cough because of their asthma?
Do they wake up during the night because of their asthma?

Asthma Control Questions – To be answered by Parent

During the last 4 weeks, on average, how many days per month, did your child have any daytime asthma symptoms?
During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?
During the last 4 weeks, on average, how many days per month, did your child wake up during the night because of asthma?

Asthma Review

The last part of the questionnaire, will ask you if you feel that your child’s asthma is well controlled and will give you the option to decide if you would like further review from a Practice Nurse for your child.
Do you feel that your child's asthma symptoms and management are well controlled at the moment?