by samysergam
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Asthma Symptoms Checklist

Asthma Symptoms

• 1. Have you experienced any of the following symptoms?

• Wheezing

• Coughing

• Tightness in chest

• Difficulty breathing

• 2. When do your symptoms begin to flare?

• After exercise or other strenuous activities

• Early in the morning

• Late at night

• Around allergy triggers (i.e., pets, pollen, dust)

• Other time

• 3. What triggered your symptoms?

• Dust

• Mold

• Stress

• Pet Dander

• Other

• 4. Did these symptoms cause you to regularly miss out on any activities?

• Yes 

• No

• 5. Does your coughing and/or wheezing continuously cause you to lose sleep?

• Yes 

•  No

• 6. Does anyone in your family have long-term asthma?

• Yes

• No

• 7. In the past month, how many asthma attacks have you had?

• 0

• 1-2

• 3-4

• More than fore

• 8. Are you currently using a daily controller medication to help manage symptoms and asthma attacks?

• Yes

• No

This checklist was created by samysergam

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