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.]
B2. Do any of your child's parents, brothers, sisters, or grandparents have asthma?
  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.]
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?
  B4a.        Did your child usually see the same doctor at the clinic or office?
B5. During the past 12 months, did your child take medicines for asthma?
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?
B7. Has a doctor or health care provider ever given you written instructions for what to do about taking medicines?
B8. Has your child had any problems taking medications at school?
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?
B10. Does your child's pillow have a zipped plastic cover for allergies?
B11. Does your child's mattress have a zipped plastic cover for allergies?
B12. Do you use a humidifier/vaporizer in your child's bedroom?
B13. Do you have carpeting (or rugs) in your child's bedroom?
B14. Do you have carpeting (or rugs) in your TV/family room?
B15. Does your kitchen have a gas stove?
B16. Do you sometimes use the gas stove to help heat your house?
B17. Is there any moisture or mildew anywhere in the house on the . . .
  a. Ceiling?
  b. Walls?
  c. Windows?
B18. Have you had any problems with . . .
  a. Cockroaches?
  b. Mice?
  c. Rats?
B19. Do you have any pets?
  a. Dog?
  b. Cat?
  c. Hamster, guinea pig, or rabbit?
B20. Do you smoke cigarettes?
B21. Does your child smoke cigarettes?
B22. How many other people who live in your home smoke?
B23. Does anyone else who takes care of your child smoke?
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?
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.]
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.]
B27. Does your child take asthma medication on his/her own? Would you say…
B28. Are you concerned about your child's behavior or emotions?
B29. Do you have any concerns about how you have been coping with things in the past few months?
B30. Have you been feeling unusually stressed lately?

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.
B32. It is possible to manage my child's asthma so he/she is free of symptoms.
B33. My child should not have problems from the asthma medicine he/she takes.
B34. I have little control over my child's asthma.
B35. I often feel helpless in dealing with my child's asthma.


C1. Are skin test results available for this child?
C2. Does the skin test indicate that your child is sensitive to dust mites?
C3. Does the skin test indicate that your child is sensitive to cockroaches?
C4. Does the skin test indicate that your child is sensitive to rodents?
C5. Does the skin test indicate that your child is sensitive to cats?
C6. Does the skin test indicate that your child is sensitive to dogs?
C7. Does the skin test indicate that your child is sensitive to mold?