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Asthma Symptoms Checklist
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 creates a private checklist in your account.