Asthma School Survey 2005

Asthma School Survey 2005 - Page 1

Identification

School Number Select one A (_) A (_) B (_) C (_) D

Student ID # 12

Parent School Asthma Pre-Interventation Survey

Personal Information

Gender Select one Female (_) Female (_) Male

Child's First Name Beth

Child's Last Name Williams

Child's Date of Birth (Required) 11-08-1995 (mm-dd-yyyy)

Age (Read Only) 9 (##)

Zip Code 12203

Your Last Name Williams Asthma School Survey 2005 - Page 2

Personal Information Your First Name Susan

Relationship to Child Mother

Home Phone Number 333-333-3333 (###-###-####)

PS School Number (Read Only) 123

Grade 5 (##)

Today's Date 10-25-2005 (mm-dd-yyyy)

Medical Information Asthma School Survey 2005 - Page 3

A s t h m a t i c

C o n d i t i o n s

H a s a h e a l t h p r o f e s s i o n Asthma School Survey 2005 - Page 4

A s t h m a t i c

C o n d i t i o n s a l e v e r t o l d y o u t h a t y o Asthma School Survey 2005 - Page 5

A s t h m a t i c

C o n d i t i o n s u r c h i l d h a s a n y o f t h e

A s t h m a t i c

C o n d i t i o n s f o l l o w i n g c o n d i t i o n s ? A s Asthma School Survey 2005 - Page 7

A s t h m a t i c

C o n d i t i o n s t h m a t i c

B r o n c h i t i s o r

W h e Asthma School Survey 2005 - Page 8

A s t h m a t i c

C o n d i t i o n s e z y

B r o n c h i t i s A s t h m a R e a Asthma School Survey 2005 - Page 9

A s t h m a t i c

C o n d i t i o n s c t i v e

A i r w a y

D i s e a s e W h e Asthma School Survey 2005 - Page 10

A s t h m a t i c

C o n d i t i o n s e z i n g

Has a health professional prescribed any medication to your child? Yes (_) Yes (_) No

How many times did your child have an emergency visit for breathing problems? 0 (##)

How many times did your child have to stay overnight in the hospital for breathing problems? 0 (##)

Does your child take medicine every day for breathing difficulties? No (_) Yes (_) No Asthma School Survey 2005 - Page 11

Select the month when your child's breathing was the worst? Select one June ( ( ( ( _ _ _ _ ) ) ) )

J A J O a p u c n r l t u i y o a l b r ( e y ( _ r _ ) ( ) ( _ A _ ) M u ) a g F y u N e s o b ( t v r _ e u ) ( m a _ b r J ) e y u r n S ( e e ( _ p _ ) t ) e M m D a b e r e c c r e h m b e r

Asthma Symptoms Asthma School Survey 2005 - Page 12

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s

D u r i n g t h e i r Asthma School Survey 2005 - Page 13

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s w o r s t b r e a t h Asthma School Survey 2005 - Page 14

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s i n g m o n t h , s e Asthma School Survey 2005 - Page 15

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s l e c t h o w o f t e Asthma School Survey 2005 - Page 16

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s n t h e f o l l o w i Asthma School Survey 2005 - Page 17

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s n g s y m p t o m s o Asthma School Survey 2005 - Page 18

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s c c u r r e d ?

W h e e Asthma School Survey 2005 - Page 19

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s z e o r w h i s t l i Asthma School Survey 2005 - Page 20

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s n g i n t h e c h e Asthma School Survey 2005 - Page 21

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s s t ? S e l e c t o n e Asthma School Survey 2005 - Page 22

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s 3 t o 6 t i m e s e a c h Asthma School Survey 2005 - Page 23

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s w e e k

N e v e r Asthma School Survey 2005 - Page 24

M o n t h l y

B r e a t h i n g

2 t i m e s e Asthma School Survey 2005 - Page 25

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s a c h w e e k o r l e Asthma School Survey 2005 - Page 26

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s s s

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t i m e s e a c h w e e Asthma School Survey 2005 - Page 28

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s k

E v e r y d a Asthma School Survey 2005 - Page 29

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s y b u t n o t a l l

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s d a y

E v e r y

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s d a y a n d a l l d a Asthma School Survey 2005 - Page 32

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s y

H a v e a c o u g Asthma School Survey 2005 - Page 33

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s h ? S e l e c t o n e 2 Asthma School Survey 2005 - Page 34

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t i m e s e a c h w e e k Asthma School Survey 2005 - Page 35

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s o r l e s s

N e v Asthma School Survey 2005 - Page 36

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e r

2 t i m e s Asthma School Survey 2005 - Page 37

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e a c h w e e k o r

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s l e s s

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s 6 t i m e s e a c h w Asthma School Survey 2005 - Page 40

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e e k

E v e r y

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s d a y b u t n o t a l Asthma School Survey 2005 - Page 42

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s l d a y

E v e r Asthma School Survey 2005 - Page 43

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s y d a y a n d a l l

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s d a y

H a v e a t i Asthma School Survey 2005 - Page 45

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s g h t c h e s t o r

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s s h o r t n e s s o f

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s b r e a t h ? S e l e c t Asthma School Survey 2005 - Page 48

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s o n e N e v e r

( _ ) Asthma School Survey 2005 - Page 49

M o n t h l y

B r e a t h i n g

N e v e r

2 t Asthma School Survey 2005 - Page 50

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s i m e s e a c h w e e k Asthma School Survey 2005 - Page 51

M o n t h l y

B r e a t h i n g

3 Asthma School Survey 2005 - Page 52

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t o

6 t i m e s e a Asthma School Survey 2005 - Page 53

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s c h w e e k

E v Asthma School Survey 2005 - Page 54

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e r y d a y b u t n o Asthma School Survey 2005 - Page 55

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t a l l d a y

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s E v e r y d a y a n d

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s a l l d a y

W a k e u Asthma School Survey 2005 - Page 58

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s p a t n i g h t f r Asthma School Survey 2005 - Page 59

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s o m w h e e z i n g ,

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s c o u g h i n g , o r

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t r o u b l e b r e a t Asthma School Survey 2005 - Page 62

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s h i n g ? S e l e c t o Asthma School Survey 2005 - Page 63

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s n e 2 t i m e s e a c h w Asthma School Survey 2005 - Page 64

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e e k o r l e s s

( _ ) Asthma School Survey 2005 - Page 65

M o n t h l y

B r e a t h i n g

N e v e r

2 t Asthma School Survey 2005 - Page 66

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s i m e s e a c h w e e k Asthma School Survey 2005 - Page 67

M o n t h l y

B r e a t h i n g

3 Asthma School Survey 2005 - Page 68

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t o

6 t i m e s e a Asthma School Survey 2005 - Page 69

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s c h w e e k

E v Asthma School Survey 2005 - Page 70

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s e r y d a y b u t n o Asthma School Survey 2005 - Page 71

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s t a l l d a y

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s E v e r y d a y a n d

M o n t h l y

B r e a t h i n g

D i f f i c u l t i e s a l l d a y

How many days of school has your child missed due to asthma? 14 (###) Asthma School Survey 2005 - Page 74

Have breathing problems stopped your child from participating in sports? No (_) Yes (_) No

If Yes, how many times in the past month? Select one

(_) 2 times a month or fewer (_) 3 to 4 times a month (_) 1 to 3 times each week (_) 4 times each week or more

How many people living in the home, including this child, have asthma? 0 (##)

Record Unique ID A413BA05-7F44-4348-B0C5-AA0C4A96D6CD

EpiSuccess eForm 11 (WF-130622-102438)