| 1. |
When I walk or play hard with friends, I have trouble breathing or I cough. |
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Yes No |
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| 2. |
When I walk up hills or stairs, I have trouble breathing or I cough. |
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Yes No |
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| 3. |
I don't like to run or play sports because I have trouble breathing or I cough. |
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Yes No |
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| 4. |
Sometimes I wake up at night with coughing or trouble breathing. |
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Yes No |
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| 5. |
Sometimes I have trouble taking a deep breath. |
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Yes No |
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| 6. |
Sometimes I make wheezing sounds in my chest. |
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Yes No |
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| 7. |
Sometimes my chest feels tight or hurts. |
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Yes No |
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| 8. |
Sometimes I cough a lot. |
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Yes No |
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| 9. |
Being outdoors or around dust or pets makes my breathing worse. |
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Yes No |
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| 10. |
It's hard to breathe in cold weather. |
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Yes No |
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| 11. |
It's hard to breathe when people smoke or there are strong odors. |
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Yes No |
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| 12. |
Colds make me cough or wheeze. |
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Yes No |
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| 13. |
I went to the doctor's office or emergency room for asthma or trouble breathing this year. |
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Yes No |
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| 14. |
I stayed in the hospital overnight for asthma or trouble breathing this year. |
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Yes No |
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| 15. |
I've been told that I have asthma. |
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Yes No |
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If you answered "no" to number 15, you have completed the Asthma Check. If you answered "yes," please answer questions 16-21: |
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| 16. |
I use my asthma inhaler two or more times a week. |
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Yes No |
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| 17. |
Sometimes my asthma medicine makes me feel bad. |
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Yes No |
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| 18. |
I only take medicine when I don't feel well. |
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Yes No |
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| 19. |
I can't do some things because of my asthma. |
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Yes No |
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| 20. |
I get scared because of my asthma. |
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Yes No |
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| 21. |
I worry that I may die from my asthma. |
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Yes No |
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| If you answered "yes" to one or more of the Asthma Check questions, print this Asthma Check, and then press the button below to score your answers. |