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	Section A asks for general information regarding the date of the assessment, the child's date of birth, and the child's age. Section A also asks for an assessment name. Choose an assessment name that will be helpful for you for future reference when reviewing the report. For example, you may choose to name the assessment the name of the child for whom you are filling out the assessment.
	Most questions in Section B and Section C are answered by choosing the appropriate answer from the pull-down list for that question. Select a response by clicking with the mouse on the pull-down menu arrow. Highlight the answer with the mouse and left click. The list of options will close, leaving your selection in the response area. If the selected answer is not correct, repeat the process. If you do not have the child's allergy skin test results, skip Section C.
	For any questions that you do not know the answer to, select 'No response.'
	If you would like to print the assessment click here to download a copy in PDF format.

Completed by:

A1. Completion Date: MM/DD/YYYY A2. Child's Date of Birth: MM/DD/YYYY

A3. Assessment Name: A4. Child's Age:

B1.	What grade is your child in? [If summer, enter the child's grade for next fall.]	Please select 0-Kindergarten 1 2 3 4 5 6 7 8 9 10 11 12 Not in school
B2.	Do any of your child's parents, brothers, sisters, or grandparents have asthma?	Please select Yes No No Response
	B2a.      All together, how many of these relatives have asthma?
B3.	Do you have a regular doctor or health care provider who treats your child's asthma? [Does not have to be an asthma specialist.]	Please select Yes No No Response
B4.	During the past 12 months, when your child went to a doctor for asthma care, was it usually in an ER or clinic/doctor's office?	Please select ER Clinic/office Both, mostly ER Both, mostly clinic/office Never had doctor's visit No Response
	B4a.        Did your child usually see the same doctor at the clinic or office?	Please select Yes No No Response
B5.	During the past 12 months, did your child take medicines for asthma?	Please select Yes No No Response
B6.	Some asthma medicines are taken only when the child is having asthma signs or symptoms. Other medicines are taken even when the child is not having symptoms.
	Does your child take medicines only when he/she is having signs or symptoms or even when he/she is not having symptoms, or both times?	Please select Only for symptoms Only when no symptoms Both No Response
B7.	Has a doctor or health care provider ever given you written instructions for what to do about taking medicines?	Please select Yes No No Response
B8.	Has your child had any problems taking medications at school?	Please select Yes No No Response
B9.	Many people have problems making and keeping doctor's appointments for their child's asthma. At other times, it is hard to get to the office or they are not open at good times.
	In the past year, have you had any of these types of problems making or keeping appointments for your child's asthma?	Please select Yes No No Response
B10.	Does your child's pillow have a zipped plastic cover for allergies?	Please select Yes No No Response
B11.	Does your child's mattress have a zipped plastic cover for allergies?	Please select Yes No No Response
B12.	Do you use a humidifier/vaporizer in your child's bedroom?	Please select Yes No No Response
B13.	Do you have carpeting (or rugs) in your child's bedroom?	Please select Yes No No Response
B14.	Do you have carpeting (or rugs) in your TV/family room?	Please select Yes No No Response
B15.	Does your kitchen have a gas stove?	Please select Yes No No Response
B16.	Do you sometimes use the gas stove to help heat your house?	Please select Yes No No Response
B17.	Is there any moisture or mildew anywhere in the house on the . . .
	a. Ceiling?	Please select Yes No No Response
	b. Walls?	Please select Yes No No Response
	c. Windows?	Please select Yes No No Response
B18.	Have you had any problems with . . .
	a. Cockroaches?	Please select Yes No No Response
	b. Mice?	Please select Yes No No Response
	c. Rats?	Please select Yes No No Response
B19.	Do you have any pets?
	a. Dog?	Please select Yes No No Response
	b. Cat?	Please select Yes No No Response
	c. Hamster, guinea pig, or rabbit?	Please select Yes No No Response
B20.	Do you smoke cigarettes?	Please select Yes No No Response
B21.	Does your child smoke cigarettes?	Please select Yes No No Response
B22.	How many other people who live in your home smoke?
B23.	Does anyone else who takes care of your child smoke?	Please select Yes No No Response
B24.	Have you ever run out of medicines for your child's asthma and not had any on hand when your child had an asthma attack?	Please select Yes No No Response
B25.	For many reasons, children do not always get their medicines exactly when they are supposed to.
	On a scale of 1 to 5, how many problems do you usually face when trying to be sure your child gets his/her medicines? [1 is no problems with medicines and 5 is a lot of problems with medicines.]	Please select 1-No problem 2 3 4 5-A lot of problems No Response
B26.	On a scale of 1 to 5, how would you rate your child's experience with taking his/her medicines exactly on schedule? [1 means never misses a dose of medicine and 5 means often misses a dose of medicine.]	Please select 1-Never misses a dose 2 3 4 5-Often misses a dose No Response
B27.	Does your child take asthma medication on his/her own? Would you say…	Please select Not at all Once in a while Quite a bit All of the time No meds No Response
B28.	Are you concerned about your child's behavior or emotions?	Please select Not at all Once in a while Quite a bit All of the time No Response
B29.	Do you have any concerns about how you have been coping with things in the past few months?	Please select Not at all Once in a while Quite a bit All of the time No Response
B30.	Have you been feeling unusually stressed lately?	Please select Not at all Once in a while Quite a bit All of the time No Response
For questions B31-B35, please indicate whether you agree or disagree with the statement.
B31.	It is possible to control my child's asthma so that he/she can play like other children.	Please select Strongly agree Agree Disagree Strongly disagree No Response
B32.	It is possible to manage my child's asthma so he/she is free of symptoms.	Please select Strongly agree Agree Disagree Strongly disagree No Response
B33.	My child should not have problems from the asthma medicine he/she takes.	Please select Strongly agree Agree Disagree Strongly disagree No Response
B34.	I have little control over my child's asthma.	Please select Strongly agree Agree Disagree Strongly disagree No Response
B35.	I often feel helpless in dealing with my child's asthma.	Please select Strongly agree Agree Disagree Strongly disagree No Response

CHILD SKIN TEST RESULTS

C1.	Are skin test results available for this child?	Please select Yes No No Response
C2.	Does the skin test indicate that your child is sensitive to dust mites?	Please select Yes No No Response
C3.	Does the skin test indicate that your child is sensitive to cockroaches?	Please select Yes No No Response
C4.	Does the skin test indicate that your child is sensitive to rodents?	Please select Yes No No Response
C5.	Does the skin test indicate that your child is sensitive to cats?	Please select Yes No No Response
C6.	Does the skin test indicate that your child is sensitive to dogs?	Please select Yes No No Response
C7.	Does the skin test indicate that your child is sensitive to mold?	Please select Yes No No Response