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Asthma review (children)

Child Asthma Review

Please use date format: DD/MM/YYYY

How to answer the childhood asthma control form

Let your child answer the first four Asthma Control questions. If your child needs help reading or understanding the question, you may help, but let your child choose which answer he / she prefers. Complete the remaining three Asthma Control questions on your own without letting your child’s response influence your answers. There are no right or wrong answers.

Asthma Control

Ask your child to complete these questions:

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

Please complete the following questions on your own:

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

If your score is between 0 and 12:

Off target

If your child’s score is 12 or less, their asthma may be very poorly controlled. Please contact the practice to arrange a review as early as possible. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 13 and 20:

On target

Your child’s asthma may not be as well controlled as it should be. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 21 and 27:

Well done

Your child’s asthma control appears to be under control over the last 4 weeks.

However, if your child is experiencing any symptoms or you have any queries, please add them in to the box at the end of this form.

Additional Questions

Is your child exposed to second hand smoke at home? Required
Does your child have a personalised asthma action plan? Required
Since your child’s last review, have they needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of their asthma? Required
Since your child’s last review, have they needed a course of steroid tablets to get their asthma under control? Required

Inhalers

Please select the types of inhalers that you use:
Required