This survey will assess what your knowledge, and will require you to answer personal

information about your asthma. Please answer to the best of your abilities.

Please state whether the statement is true or false:

1. People with asthma worry a lot

2. People with asthma can drink milk and eat yogurt
3. Having the flu can cause an asthma attack
4. Smoking is OK for people with asthma
5. An asthma attack is caused by redness in the lungs
6. Most children with asthma are smaller than other children
7. Medicines that keep asthma from happening should be taken every day.
8. A puffer (inhaler) should be used when a person has an asthma attack
9. Asthma happens more at night
10. Some asthma medicines can hurt the heart
11. Rest is needed to stop an asthma attack
12. An asthma attack can happen suddenly without warning
13. When asthma is OK, all medicines can be stopped
14. Children with asthma can play sport

Please answer the following questions with a:

0= all of the time, 1= most of the time, 2= some of the time, 3= hardly any of the time, 4=

none of the time

15. How often did your asthma make you feel FRUSTRATED during the past week?
16. How often did your asthma make you feel TIRED during the past week?
17. How often did you feel WORRIED, CONCERNED OR TROUBLED because of your

asthma during the past week?

18. How often did your asthma make you feel ANGRY during the past week?
19. How often did you feel IRRITABLE (cranky) during the past week?
20. How often did you feel FRUSTRATED BECAUSE YOU COULDNT KEEP UP WITH

OTHERS during the past week?

21. How often did you feel UNCOMFORTABLE because of your asthma during the past week?
22. How often did you have trouble SLEEPING AT NIGHT because of your asthma during the

past week?
23. How often did you feel FRIGHTENED BY AN ASTHMA ATTACK during the past week?
24. How often did you have difficulty taking a DEEP BREATH during the past week?

Please answer the following questions with a:

0= extremely bothered, 1=bothered, 2= somewhat bothered, 3= bothered a bit, 4= not

bothered

25. How much have you been bothered by your asthma in during the past week?
26. How much did COUGHING bother you in the past week?
27. How much did ASTHMA ATTACKS bother you during the past week?
28. How much did TIGHTNESS IN YOUR CHEST bother you during the past week?
29. How often did you feel DIFFERENT or LEFT OUT because of your asthma during the past

week?
30. How much did SHORTNESS OF BREATH bother you during the past week?
31. Think about all the activities that you did during the past week. How much were you

bothered by your asthma doing these activities?

Please answer the following questions with a:

0= four or more times a night, 1= two to three nights, 2= once a week, 3= once or twice, 4=

not at all.

32. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing,

shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the

morning?

33. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer

medication (such as albuterol)?

Please answer the following question with a:

0= not controlled, 1= poorly controlled, 2= somewhat controlled, 3= well controlled, and 4=

completely controlled.

34. How would you rate your asthma control during the past 4 weeks?