Asthma Screening Tool—help your patients’ parents convey their child's asthma symptoms

Asthma symptoms often seem like other respiratory problems. Furthermore, parents may not know how to speak to their child about asthma symptoms or report these symptoms to their health care team.

The Asthma Screening Tool contains questions about established or suspected asthma. While not intended to diagnose asthma, this form may enable your patients’ parents to better convey their child's asthma symptoms to you.

This form contains questions for patients with suspected or established asthma.

This form is not intended to be used to diagnose asthma.

Mark the choices that best describe how your child is feeling and the symptoms that your child has experienced.

Discuss any questions you may have with your child's doctor/healthcare provider.

1. Has your child ever been diagnosed with asthma?	Yes	No
1a. If yes, at what age was he or she       diagnosed?
1b. Do you believe he or she still has asthma?	Yes	No
2. Has your child ever been tested for allergies?	Yes	No
2a. If yes, date of allergy testing:
2b. Did he or she test positive?	Yes	No
2c. What allergies did he or she test positive       for?
3. Are there smokers in your house?	Yes	No
4. Is your child exposed to second-hand smoke?	Yes	No
5. What symptoms has your child experienced? Check all that apply.
Persistent coughing Wheezing (a whistling sound while breathing) Difficulty breathing and shortness of breath, especially during or       after activity Chest tightness or complaints of chest hurting
6. What is the longest your child has experienced any of these symptoms?
Less than 1 month 1–6 months 7-12 months More than 1 year
7. How often does your child experience coughing, wheezing, shortness of breath, chest tightness or complaints of chest hurting?
Less than or equal to 2 times a week More than 2 times a week but less than 1 time a day Every day Continuously
8. When does your child experience coughing, wheezing, shortness of breath, or chest tightness? Check all that apply.
8a. During the day	Yes	No
8b. At night, waking him or her up	Yes	No
8c. During or right after exercising	Yes	No
9. What makes your child's symptoms worse? Check all that apply and fill in the blanks.
Smoke Cold/flu Prolonged laughter or crying Animals Cold air Vigorous activity Foods: Dust Pollen Strong odors and sprays Mold
10. In the past 2 weeks, have these symptoms kept your child from doing any activities?	Yes	No
If yes, what activities were they?
11. In the past few months, have these symptoms caused your child to miss school?	Yes	No
12. In the past few months, has your child had to go to the emergency room or hospital because of these symptoms?	Yes	No
If yes, please described what happened.
13. Please list all medicines, including over-the-counter medicines, that your child is currently taking, or has taken in the last month.
14. Does anyone else in your family have asthma, hay fever (allergic rhinitis), or eczema (atopic dermatitis)?

A NOTE TO PHYSICIANS: This form is intended to be used only as an adjunct to your history-taking of patients with suspected or established asthma. It should be discussed with your patient. (This form has not been validated as a diagnostic tool.)

Learn about asthma screening events

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