| When I walk or do simple chores, I have trouble breathing or I cough. |
|
Yes No |
| |
|
|
| When I perform heavier work, such as walking up hills and stairs or doing chores that involve lifting, I have trouble breathing or I cough. |
|
Yes No |
| |
|
|
| Sometimes I avoid exercising or taking part in sports like jogging, swimming, tennis or aerobics because I have trouble breathing or I cough. |
|
Yes No |
| |
|
|
| I have been unable to sleep through the night without coughing attacks or shortness of breath. |
|
Yes No |
| |
|
|
| Sometimes I can't catch a good, deep breath. |
|
Yes No |
| |
|
|
| Sometimes I make wheezing sounds in my chest. |
|
Yes No |
| |
|
|
| Sometimes my chest feels tight. |
|
Yes No |
| |
|
|
| Sometimes I cough a lot. |
|
Yes No |
| |
|
|
| Dust, pollen and pets make my breathing more difficult. |
|
Yes No |
| |
|
|
| Cold weather makes my breathing more difficult. |
|
Yes No |
| |
|
|
| My breathing problem gets worse when I'm around tobacco smoke, fumes or strong odors. |
|
Yes No |
| |
|
|
| When I catch a cold it often goes to my chest. |
|
Yes No |
| |
|
|
| I made one or more emergency visits to a doctor in the past year because of my breathing problems. |
|
Yes No |
| |
|
|
| I had one or more overnight hospitalizations due to breathing problems in the past year. |
|
Yes No |
| |
|
|
|
Answer the following questions if you ever have been diagnosed with asthma: |
| |
|
|
| I feel like I use my asthma inhaler too often. |
|
Yes No |
| |
|
|
| Sometimes I don't like the way my asthma medicine makes me feel. |
|
Yes No |
| |
|
|
| My asthma medicine doesn't control my asthma. |
|
Yes No |
| |
|
|
| My asthma controls my life more than I would like. |
|
Yes No |
| |
|
|
| I feel tension or stress because of my asthma. |
|
Yes No |
| |
|
|
| I worry that my asthma affects my health or may even shorten my life. |
|
Yes No |