Paediatric Asthma Symptom Scale Paediatric Asthma Symptom Scale Your Name Age Gender ---FemaleMale Surgery Doctor Date PLEASE ANSWER THE FOLLOWING 8 QUESTIONS OF THIS HEALTH SURVEY COMPLETELY, HONESTLY AND WITHOUT INTERRUPTIONS. During the last 4 weeks, HOW OFTEN did your child have any of the following symptoms? 1. Cough? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 2. Wheezing? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 3. Shortness of breath? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 4. Asthma attack? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 5. Chest pain? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 6. During the past 4 weeks, how many ASTHMA ATTACKS did your child have? 7. During the past 4 weeks, how often has your child been AWAKENED AT NIGHT because of his/her asthma symptoms? ---All of the timeMost of the timeA good bit of the timeSome of the timeA little bit of the timeNone of the time 8. Overall, how would you rate the SEVERITIY OF YOUR CHILD’S ASTHMA? ---Very mildMildModerateSevereVery severe THANK YOU FOR COMPLETING THIS QUESTIONNAIRE STAFF USE ONLY Participants NHS Number: Researchers Name: NHS Site Number: NHS Site Name: Postcode:
