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Asthma Symptoms Checklist

Asthma Symptoms

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

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• Wheezing

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• Coughing

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• Tightness in chest

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• Difficulty breathing

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• 2. When do your symptoms begin to flare?

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• After exercise or other strenuous activities

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• Early in the morning

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• Late at night

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

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• Other time

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• 3. What triggered your symptoms?

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• Dust

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• Mold

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• Stress

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• Pet Dander

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• Other

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

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• Yes 

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• No

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

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• Yes 

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•  No

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

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• Yes

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• No

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

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• 0

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• 1-2

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• 3-4

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• More than fore

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

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• Yes

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• No

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This checklist was created by samysergam

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