Asthma School Survey 2005

Asthma School Survey 2005 - Page 1Asthma School Survey 2005IdentificationSchool Number Select one A (_) A (_) B (_) C (_) DStudent ID # 12 Parent School Asthma Pre-Interventation SurveyPersonal InformationGender Select one Female (_) Female (_) MaleChild'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 2Personal 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 3A s t h m a t i cC o n d i t i o n sH a s a h e a l t h p r o f e s s i o n Asthma School Survey 2005 - Page 4A s t h m a t i cC 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 5A s t h m a t i cC 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 eAsthma School Survey 2005 - Page 6A s t h m a t i cC 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 7A s t h m a t i cC o n d i t i o n s t h m a t i cB r o n c h i t i s o rW h e Asthma School Survey 2005 - Page 8A s t h m a t i cC o n d i t i o n s e z yB r o n c h i t i s A s t h m a R e a Asthma School Survey 2005 - Page 9A s t h m a t i cC o n d i t i o n s c t i v eA i r w a yD i s e a s e W h e Asthma School Survey 2005 - Page 10A s t h m a t i cC o n d i t i o n s e z i n gHas a health professional prescribed any medication to your child? Yes (_) Yes (_) NoHow 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 11Select 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 rAsthma Symptoms Asthma School Survey 2005 - Page 12M o n t h l yB r e a t h i n gD i f f i c u l t i e sD u r i n g t h e i r Asthma School Survey 2005 - Page 13M o n t h l yB r e a t h i n gD 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 14M o n t h l yB r e a t h i n gD 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 15M o n t h l yB r e a t h i n gD 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 16M o n t h l yB r e a t h i n gD 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 17M o n t h l yB r e a t h i n gD 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 18M o n t h l yB r e a t h i n gD 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 19M o n t h l yB r e a t h i n gD 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 20M o n t h l yB r e a t h i n gD 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 21M o n t h l yB r e a t h i n gD 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 22M o n t h l yB r e a t h i n gD 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 23M o n t h l yB r e a t h i n gD 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 24M o n t h l yB r e a t h i n gD i f f i c u l t i e s( _ )2 t i m e s e Asthma School Survey 2005 - Page 25M o n t h l yB r e a t h i n gD 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 26M o n t h l yB r e a t h i n gD i f f i c u l t i e s s s( _ )3 t o6Asthma School Survey 2005 - Page 27M o n t h l yB r e a t h i n gD 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 28M o n t h l yB r e a t h i n gD i f f i c u l t i e s k( _ )E v e r y d a Asthma School Survey 2005 - Page 29M o n t h l yB r e a t h i n gD i f f i c u l t i e s y b u t n o t a l lAsthma School Survey 2005 - Page 30M o n t h l yB r e a t h i n gD i f f i c u l t i e s d a y( _ )E v e r yAsthma School Survey 2005 - Page 31M o n t h l yB r e a t h i n gD 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 32M o n t h l yB r e a t h i n gD i f f i c u l t i e s yH a v e a c o u g Asthma School Survey 2005 - Page 33M o n t h l yB r e a t h i n gD 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 34M o n t h l yB r e a t h i n gD 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 35M o n t h l yB r e a t h i n gD 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 36M o n t h l yB r e a t h i n gD i f f i c u l t i e s e r( _ )2 t i m e s Asthma School Survey 2005 - Page 37M o n t h l yB r e a t h i n gD i f f i c u l t i e s e a c h w e e k o rAsthma School Survey 2005 - Page 38M o n t h l yB r e a t h i n gD i f f i c u l t i e s l e s s( _ )3 t oAsthma School Survey 2005 - Page 39M o n t h l yB r e a t h i n gD 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 40M o n t h l yB r e a t h i n gD i f f i c u l t i e s e e k( _ )E v e r yAsthma School Survey 2005 - Page 41M o n t h l yB r e a t h i n gD 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 42M o n t h l yB r e a t h i n gD i f f i c u l t i e s l d a y( _ )E v e r Asthma School Survey 2005 - Page 43M o n t h l yB r e a t h i n gD i f f i c u l t i e s y d a y a n d a l lAsthma School Survey 2005 - Page 44M o n t h l yB r e a t h i n gD i f f i c u l t i e s d a yH a v e a t i Asthma School Survey 2005 - Page 45M o n t h l yB r e a t h i n gD i f f i c u l t i e s g h t c h e s t o rAsthma School Survey 2005 - Page 46M o n t h l yB r e a t h i n gD i f f i c u l t i e s s h o r t n e s s o fAsthma School Survey 2005 - Page 47M o n t h l yB r e a t h i n gD 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 48M o n t h l yB r e a t h i n gD i f f i c u l t i e s o n e N e v e r( _ ) Asthma School Survey 2005 - Page 49M o n t h l yB r e a t h i n gD i f f i c u l t i e sN e v e r( _ )2 t Asthma School Survey 2005 - Page 50M o n t h l yB r e a t h i n gD 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 51M o n t h l yB r e a t h i n gD i f f i c u l t i e s o r l e s s( _ )3 Asthma School Survey 2005 - Page 52M o n t h l yB r e a t h i n gD i f f i c u l t i e s t o6 t i m e s e a Asthma School Survey 2005 - Page 53M o n t h l yB r e a t h i n gD i f f i c u l t i e s c h w e e k( _ )E v Asthma School Survey 2005 - Page 54M o n t h l yB r e a t h i n gD 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 55M o n t h l yB r e a t h i n gD i f f i c u l t i e s t a l l d a y( _ )Asthma School Survey 2005 - Page 56M o n t h l yB r e a t h i n gD i f f i c u l t i e s E v e r y d a y a n dAsthma School Survey 2005 - Page 57M o n t h l yB r e a t h i n gD i f f i c u l t i e s a l l d a yW a k e u Asthma School Survey 2005 - Page 58M o n t h l yB r e a t h i n gD 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 59M o n t h l yB r e a t h i n gD i f f i c u l t i e s o m w h e e z i n g ,Asthma School Survey 2005 - Page 60M o n t h l yB r e a t h i n gD i f f i c u l t i e s c o u g h i n g , o rAsthma School Survey 2005 - Page 61M o n t h l yB r e a t h i n gD 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 62M o n t h l yB r e a t h i n gD 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 63M o n t h l yB r e a t h i n gD 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 64M o n t h l yB r e a t h i n gD 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 65M o n t h l yB r e a t h i n gD i f f i c u l t i e sN e v e r( _ )2 t Asthma School Survey 2005 - Page 66M o n t h l yB r e a t h i n gD 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 67M o n t h l yB r e a t h i n gD i f f i c u l t i e s o r l e s s( _ )3 Asthma School Survey 2005 - Page 68M o n t h l yB r e a t h i n gD i f f i c u l t i e s t o6 t i m e s e a Asthma School Survey 2005 - Page 69M o n t h l yB r e a t h i n gD i f f i c u l t i e s c h w e e k( _ )E v Asthma School Survey 2005 - Page 70M o n t h l yB r e a t h i n gD 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 71M o n t h l yB r e a t h i n gD i f f i c u l t i e s t a l l d a y( _ )Asthma School Survey 2005 - Page 72M o n t h l yB r e a t h i n gD i f f i c u l t i e s E v e r y d a y a n dAsthma School Survey 2005 - Page 73M o n t h l yB r e a t h i n gD i f f i c u l t i e s a l l d a yHow many days of school has your child missed due to asthma? 14 (###) Asthma School Survey 2005 - Page 74Have breathing problems stopped your child from participating in sports? No (_) Yes (_) NoIf 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 moreHow 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)

Asthma School Survey 2005

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