| Answer these questions by checking "yes" or "no." Do this just before each doctor's visit.
In the past 2 weeks |
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| 1. Have you coughed, wheezed, felt short of breath, or had chest tightness: | ||
| - During the day? | _______ Yes | _______ No |
| - At night, causing you to wake up? | _______ Yes | _______ No |
| - During or soon after exercise? | _______ Yes | _______ No |
| 2. Have you needed more "quick-relief" medicine than usual? | _______ Yes | _______ No |
| 3. Has your asthma kept you from doing anything you wanted to do? | _______ Yes | _______ No |
| If yes, what was it? | ||
| ____________________________________________________________ | ||
| ____________________________________________________________ | ||
| 4. Have you asthma medicines caused you any problems, like shakiness, sore throat, or upset stomach? | _______ Yes | _______ No |
| In the past few months: | ||
| 5. Have you missed school or work because of you asthma? | _______ Yes | _______ No |
| 6. Have you gone to the emergency room or hospital because of your asthma? | _______ Yes | _______ No |
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| What Your Answers mean | ||
| - All "no" asnwers? - Your asthma is under control. - One or more "yes" answers? - Something needs to be done. Read the guide on how to get your asthma under control and talk to your doctor. |
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