Asthma Survey Do You Have Asthma?


		treatments

		my medications
		my lifestyle
		my child's asthma
		my allergies
		my recent attack

Asthma is common—it affects over 17 million people in the United States, including over 5 million children. Without proper treatment, a person with asthma may miss work, limit their exercise, or even need emergency treatment or hospitalization. Fortunately, early detection, care, and treatment of asthma can help a person with asthma live a full, active life.

Below are a few questions that may help you and your healthcare professional assess whether or not you have asthma. Once you've answered the questions, print this page and bring it with you when you talk to your healthcare professional.

	Sometimes I cough or have trouble breathing while completing daily activities. Yes No

	Sometimes I avoid exercising because I have problems breathing, or I start coughing. Yes No

	Sometimes I wake up at night because of coughing or shortness of breath. Yes No

	Sometimes, especially when it is very cold or very hot outside, I avoid going out because I may have trouble breathing. Yes No

	I have missed work or school because of breathing problems. Yes No

	Sometimes I feel short of breath. Yes No

	Sometimes my chest feels tight. Yes No

	Sometimes I hear myself wheezing (difficulty breathing accompanied by a whistling sound, especially when breathing out). Yes No

	Sometimes I have coughing spells. Yes No

	Dust, pollen, or pets make me cough, wheeze, or have trouble breathing. Yes No

	My breathing may be worse in very cold weather. Yes No

	Sometimes I have trouble breathing when it's very hot outside. Yes No

	My breathing gets worse when I'm around tobacco smoke, fumes, or strong odors. Yes No

	When I catch a cold, it often goes to my chest and I have trouble breathing. Yes No