Child Annual Asthma Review Child Annual Asthma Review Please complete the online form below to submit your child’s annual asthma review First Names Surname Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Please answer the following questions:1. Step 1: Let your child respond to the first four questions (1 to 4). If your child needs help in reading or understanding the question, you may help, but let your child select the response. Question 1: How is your Asthma today? Very bad (0) Bad (1) Good (2) Very Good (3) 2. Question 2: How much of a problem is your asthma when you run, exercise or play sports? It’s a big problem, I can’t do what I want to do (0) It’s a problem and I don’t like it (1) It’s a bit of a problem but its okay (2) It’s not a problem (3) 3. Question 3: Does your Asthma make you cough? Yes, all the time (0) Yes, most of the time (1) Yes, sometimes (2) No, never (3) 4. Question 4: Does your asthma make you wake up during the night? Yes, all the time (0) Yes, most of the time (1) Yes, sometimes (2) No, never (3) 5. Step 2: Complete the remaining questions on your own and without letting your child's responses influence your answers. Question 5: During the last 4 weeks, how many days did your child have any daytime asthma symptoms? None (5) 1 to 3 days (4) 4 to 10 days (3) 11 to 18 (2) 19 to 24 (1) Everyday (0) 6. Question 6: During the last 4 weeks, how many days did your child wheeze during the day because of asthma? None (5) 1 to 3 days (4) 4 to 10 days (3) 11 to 18 days (2) 19 to 24 days (1) Everyday (0) 7. Question 7: During the last 4 weeks, how may days did your child wake up during the night because of asthma? None (5) 1 to 3 days (4) 4 to 10 days (3) 11 to 18 days (2) 19 to 24 days (1) Everyday (0) 9. Does your child have an Asthma Management Plan? Yes and I am happy with it Yes but I think it needs changing No Not sure 9. Does your child have a preventer inhaler? Yes, a Metered Dose Inhaler (e.g. Clenil, QVar, Seretide, Evohaler, Fostair, Flutiform) Yes, an Accuhaler Yes, an Autohaler Yes, a Breezhaler Yes, and Easi-Breathe Yes, and Easyhaler Yes, and Ellipta Yes, a Forspiro/Airflusal Yes, a Genuair Yes, a Handihaler (Spiriva) Yes, a NEXThaler Yes, a Respimat Yes, a Spiromax Yes, a Turbhaler (e.g. symbicort, pulmicort, bricanyl) No they do not have a preventer inhaler 10. How many puffs does your child take of their preventer inhaler in the MORNING? 0 puffs in the morning 1 puff in the morning 2 puffs in the morning 3 or more puffs in the morning Not applicable – my child doesn’t use a prevent inhaler If your child’s inhaler contains a steroid, they should brush their teeth or rinse their mouth with water and spit it out after every use to prevent mouth infections.11. How may puffs does your child take of their preventer inhaler at NIGHT? 0 puffs at night 1 puff at night 2 puffs at night 3 or more puffs at night Not applicable – My child doesn’t use a preventer inhaler 12. Has your child had an exacerbation of their Asthma in the last year? No, 0 exacerbations Yes, 1 exacerbation Yes, 2 exacerbations Yes, 3+ exacerbations An asthma exacerbation is a sudden progressive worsening of your symptoms such as shortness of breath, wheezing, cough and chest tightness. Exacerbations often require additional treatment, such as steroid tablets or hospital treatment.13. In the last year, has your child been prescribed any oral steroids such as prednisolone tablets as a result of an exacerbation of their asthma? No, 0 course of oral steroids Yes, 1 course of oral steroids Yes, 2 courses of oral steroids Yes, 3 or more courses of oral steroids 14. Does your child smoke or are they exposed to second-hand smoke? Not exposed to second-hand smoke Exposed to second-hand smoke Never smoked Light smoker (1-9 cigarettes per day) Moderate smoker (10-19 cigarettes per day) Heavy smoker (20-39 cigarettes per day) Very heavy smoker (40+ cigarettes per day) 15. What triggers your Asthma?Taking your asthma medicine each day will help reduce your reaction to these triggers. Avoiding them where possible will also help. People with allergies need to be extra careful as attacks can be more severe.
