Asthma

Patient Self-Assessment Form for Environmental and Other Factors That Can Make Asthma Worse

Patient Name:_________________________________

Date: _________

Circle No or Yes in each of the following questions and then share the result with your doctor.

If no, go here, If yes continue with these:

• Are there pets or animals in your home, school, or day care? No Yes
• Is there moisture or dampness in any room of your home? No Yes
• Have you seen mold or smelled musty odors any place in your home? No Yes
• Have you seen cockroaches in your home? No Yes
• Do you use a humidifier or swamp cooler in your home? No Yes

If no, go here, If yes, do your symptoms get worse in the

• Early spring? (Trees) No Yes
• Late spring? (Grasses) No Yes
• Late summer to autumn? (Weeds) No Yes
• Summer and fall? (Altemaria, Cladosporium) No Yes

Do you smoke? No Yes

Does anyone smoke at home, work, or day care? No Yes

Is a wood-burning stove or fireplace used in your home? No Yes

Are kerosene, oil, or gas stoves or heaters used without vents in your home? No Yes

Are you exposed to fumes or odors from cleaning agents, sprays, or other chemicals? No Yes

Do you cough or wheeze during the week, but not on weekends when away from work or school? No Yes

Do your eyes and nose get irritated soon after you get to work or school? No Yes

Do your coworkers or classmates have symptoms like yours? No Yes

Are isocyanates, plant or animal products, smoke, gases, or fumes? No Yes

Is it cold, hot, dusty, or humid where you work? No Yes

Do you have a stuffy nose or postnasal drip, either at certain times of the year or year-round? No Yes

Do you sneeze often or have itchy, watery eyes? No Yes

Do you have heartburn? No Yes

Does food sometimes come up into your throat? No Yes

Have you had coughing, wheezing, or shortness of breath at night in the past 4 weeks? No Yes

Does your infant vomit then cough or have wheezy cough at night? No Yes

Are these symptoms worse after feeding? No Yes

Have you had wheezing, coughing, or shortness of breath after eating shrimp, dried fruit, or canned or processed potatoes? No Yes

After-drinking beer or wine? No Yes

Are you taking any prescription medicines or over-the-counter medicines? No Yes

If yes, which ones? ______________________________________________

Do you use eye drop? No Yes

Do you use any medicines that contain beta-blockers (e.g., blood pressure medicine)? No Yes

Do you ever take aspirin or other nonsteroidal anti-inflammatory drugs (like ibuprofen)? No Yes

Have you ever had coughing, wheezing, chest tightness, or shortness of breath after taking any medication? No Yes

Do you cough, wheeze, have chest tightness, or feel short of breath during or after exercising? No Yes