QUESTIONNAIRE

BIOGRAPHIC DATA Name (Optional): Address: Age: Birthday: Current Occupation: Gender: Nationality: Civil Status:

Instruction: Check what applies. HISTORY: 1. How old are you when you were diagnosed with asthma? ________________________ 2. How many times does your asthma occur in a month? __ Once __ Twice __ Thrice __ Others: Please Specify _____________ 3. When was the last time you have experienced an asthma attack? ____________________________ 4. Is your asthma? ___Hereditary ___Acquired

*If your asthma is Hereditary answers the questions 5-8. If your asthma is Acquired proceed to question number 9.

5. A. Do you have any known family member or relative who has asthma? ___YES ___NO

B. If yes, from what side of the family is asthma present? ___Father Side ___Mother Side ___Both

6. Do you have any siblings who also have asthma? ___YES ___NO

7. How many in your family has asthma? ___One ___Three ___Two ___Others: Please specify ______________

8. How often do you experience cough and colds in a month? ___Frequently ___Rare ___Sometimes ___Never

9. What factor mostly triggers your asthma attacks? CATEGORY: A. If FOOD, put a check on what applies: 10.What kind of food products triggers your asthma? ___Poultry ___Beef ___Fish ___Pork

___Shrimps and Crabs ___Others: Please specify _________ B. If ENVIRONMENT, answer the questions below: 11. Does your current occupation expose you to airway irritants? ___YES ___NO

12. How often are you exposed to these irritants? ___Frequent ___Rare ___Seldom ___Never

13. Does your current work environment have the following irritants? ___Chemicals ___Chlorine ___Spray paint ___Ammonia

14.During what kind of weather do you usually have asthma? ___Sunny ____Rainy ____Both

15.Do you think that the sudden change of the weather triggers your asthma? ___YES ___NO

C. If POLLENS, answer the questions below: 16. Do you have any allergies to pollens? ___YES ___NO

17.Do you have a Flowering Plant or Tree near your house? ___YES ___NO

D. If INSECTS, answer the questions below: 18.Do you have any allergy to insect bites? __YES __NO

19.What kind of insect usual causes your asthma? ___Bee/Bee Sting ___Cockroach

___Others: Please specify___________ E. If ANIMALS, answer the questions below : 20.Do you have pets in your house? ___YES ___NO

21.What kind of pets do you have? ___Dog ___Chicken ___Cat ___Monkey

___Others: Please specify _______________ 22. How frequent do you come in contact with them? ___Frequent ___Rare __Seldom __Never

F. If LIFESTYLE, answer the questions below: 23.Do you smoke? ___YES ___NO

24.How many stick/s of cigarette do you usually consume per day? ___One ___Five ____Three ____1 Pack

___Others: Please specify____________ 25. What time do you usually sleep? ___6 PM ___10 PM ___8 PM ___1 AM

___Others: please specify ___________ 26.How many hours do you spend sleeping? ____8 hours ____6 hours ____ 4 hours ____ 1 Hour

____Others: Please specify __________ 27.How frequent do you exercise? ___Regularly ___Seldom

___Rare

___Never

28.What kind of exercise do you do? ___ Jogging ___Swimming ____Walking ____Others: Please specify___________

29.How many hours do you spend for exercise? ___ 1-2 Hours ___ 5-6 Hours ____3-4 Hours ____Others: Specify__________

G. If CHORES, answer the questions below: 30.Do you participate in Households chores? ___YES ___NO

31.Who does your household chores? ___You alone ___Other People ___You and other family member ___Others: Specify_____________

32. What chores do you usually do? ___Dusting ___Cleaning Windows ___Cooking ___Doing Laundry ___Watery Plants ___Sweeping the floor

___Others: Specify______________ 33. How many times do you do dusting in your house? ___Frequent ___Rare ___Seldom ___Never