Asthma Questionnaire

This questionnaire helps us know the impact of asthma on your well being and daily life.

• Please complete this questionnaire before you come to your clinic visit, so we have all the information we need to manage your asthma better.

• Kindly take the next 15 to 30 minutes to complete the questionnaire, following the instructions at the head of each section.

• You will be able to review your responses at the end of the questionnaire.

YOUR ASTHMA HISTORY:

At what age did you start regularly experiencing asthma symptoms?
(cough, wheeze, shortness of breath, chest tightness)

years of age

First visit: In the last 12 months:

How many times have you needed a course (3 or more days) of steroid medication (e.g. prednisolone via tablets) because of worsening asthma?

If you can recall the dates when the above events of worsening asthma occurred, please provide them here:
Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. month and year)

I cannot recall the date

Did any of the above events result in a:

Emergency room visit
Hospital admission or intensive care
None of the above
Do not know

How many times have you been treated in an emergency department because of worsening asthma?

How many times have you been admitted to hospital or intensive care because of worsening asthma?

YOUR ASTHMA SYMPTOMS AND CONTROL:

Think back to the last 4 weeks (28 days).

Please tell us about your asthma symptoms in a typical week within these last 4 weeks (28 days).

Please select the relevant number from 0 to 7

How many days in a typical week in the last 4 weeks have you experienced asthma symptoms?
(cough, wheeze, shortness of breath, chest tightness)

How many days in a typical week in the last 4 weeks has your asthma interfered with your usual activities?
(housework, work, school, etc.)

How many nights in a typical week in the last 4 weeks have you been affected or woken by asthma symptoms?
(cough, wheeze, shortness of breath, chest tightness)

How many days have you used your reliever or rescue inhaler?
(Reliever or rescue inhaler: provide quick relief for chest tightening and breathing difficulties e.g. Albuterol, Ventolin, ProAir, Proventil)

ABOUT YOUR ASTHMA MEDICATION:

Are you currently receiving any of these asthma medications given by injection (e.g. every month, every two weeks) also known as "biologics"?

Xolair (Omalizumab)
Nucala (Mepolizumab)
Cinqair (Reslizumab)
Fasenra (Benralizumab)
Dupixent (Dupilimab)
None of the above

Have you stopped or changed your biologic medication in the last 12 months?

Yes

Please tell us the reason for the change or stop if you know.
(You may select any or all reasons that apply to you)

Asthma medication was not effective
I faced side effects from my asthma medication
Asthma medication is not covered by insurance or
subsidized by the health system or not approved for use
I prefer not to continue on the asthma medication
Other
Do not know

Are you currently taking any steroid tablets on a regular basis for your asthma?
(e.g. prednisolone, prednisone tablets most days as a long-term arrangement, and NOT short courses)

Prednisolone (Orapred�, PediaPred�, Millipred�, etc)
Prednisone (Deltasone�)
Others:
I do not take any steroid tablets

Have you stopped or changed your regular steroid tablet medication in the last 12 months?

Yes

Please tell us the reason for the change or stop if you know.
- (You may select any or all reasons that apply to you)

switch_reason

CONDITIONS RELATED TO ASTHMA:

Please indicate if you have previously had or currently have any of the following conditions:

Do you experience allergic rhinitis (or hay fever)?
• Seasonal or short-term (<12 weeks) symptoms such as sneezing, runny and/or itchy nose
• Caused by irritation and congestion in the nose due to allergens; NOT a cold

Yes: Current
Yes: Past
Never
Do not know

Do you see a specialist for persistentrhinitis (or chronic rhinosinusitis)?
• Persistent symptoms (> 12 weeks) such as sneezing, runny and/or itchy nose
• Caused by irritation and congestion in the nose (NOT caused by seasonal allergens or a cold)

Yes: Current
Yes: Past
Never
Do not know

Do you see a skin specialist for eczema (or atopic dermatitis)?
• Causes severe itching, redness, and scaling of the skin

Yes: Current
Yes: Past
Never
Do not know

Do you see a specialist for sinus disease and been told you have nasal polyps?
• Benign growths within the nose or sinuses
• You may have the following symptoms: trouble breathing through the nose, loss of smell, nasal stuffiness, or a runny nose
• You may have also had nasal examinations/scans to confirm the presence of these growths or a surgery to remove the nasal polyps

Yes: Current
Yes: Past
Never
Do not know

OTHER CONDITIONS:

Do you currently have, or have you ever had any of the following health problems or conditions?

You could have been told by your physician to have these conditions or may have received/currently be receiving treatment for these conditions. If so, please select "Yes".

Osteoporosis

Yes

Do not know

If you can recall the date when this event occurred, please indicate here:
Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. year).

I cannot recall the date

Diabetes

Yes

Do not know

I cannot recall the date

Cataract
(you may have undergone a surgery to remove your cataract/s)

Yes

Do not know

I cannot recall the date

Glaucoma
(you may have undergone a surgery to remove your cataract/s)

Yes

Do not know

I cannot recall the date

Sleep apnea
(you may be receiving treatment via a CPAP machine during sleep)

Yes

Do not know

I cannot recall the date

Kidney Failure
(you may be requiring dialysis or a kidney transplant)

Yes

Do not know

I cannot recall the date

Peptic/Stomach or intestinal ulcers
(painful sores that form in the stomach or the lining of the intestine)

Yes

Do not know

I cannot recall the date

Pneumonia
(lung infection caused by bacteria/fungi that lead to coughing, fever, chest pains, etc)

Yes

Do not know

I cannot recall the date

Heart Failure

Yes

Do not know

I cannot recall the date

Heart Attack

Yes

Do not know

I cannot recall the date

Stroke

Yes

Do not know

I cannot recall the date

Blood clots in the bloodstream
(where blood clots circulating in the veins affect the lungs (Pulmonary embolisms) or other parts of the body (venous thromboembolisms))

Yes

Do not know

I cannot recall the date

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless

Not at all
Several days
More than half the days
Nearly every day

Feeling nervous, anxious or on edge

Not at all
Several days
More than half the days
Nearly every day

Not being able to stop or control worrying

Not at all
Several days
More than half the days
Nearly every day

CANCER:

Have you ever been or are you currently diagnosed with cancer?

Yes

If yes, please provide any details available on the cancer type and/or the location of the cancer
- Leukemia, Lung cancer, Ovarian cancer, Stomach cancer, Breast cancer, Bladder cancer, etc.

If you are able to recall the date when the cancer started, please provide it here.
- Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. year).

I cannot recall the date

If remission, if you are able to recall the date when the cancer ended, please provide it here.
Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. year).

I cannot recall the date

ABOUT COVID-19:

Please tell us about how COVID-19 has affected you

Have you had any of these symptoms of COVID-19 since January 2020?
Please select all that apply

No, I have not had any symptoms
Fever or high temperature
Persistent dry cough
Loss or change of smell or taste
Shortness of breath
Loss of appetite
Chest pain
Fatigue or tiredness
Aches and pains
Headache
Abdominal pain
Diarrhoea
Confusion or disorientation

When did your symptoms start?
Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. year).

I cannot recall the date

Do you believe that you had COVID-19 infection?

Yes

Do not know

Have you been diagnosed with COVID-19 or told by a healthcare professional that you may have COVID-19?

Yes

Do not know

What kind of medical attention did you seek for COVID-19 infection or symptoms?
Please tick all that apply

No, I did not seek any medical attention
Consulted GP/practice nurse over the phone or online
Consulted GP/practice nurse face-to-face
Visited Accident and Emergency
Admitted to hospital
Admitted to intensive or critical care
Other:

Have you been tested for COVID-19?

Yes

Do not know

If you can recall the date of the test, please indicate here:
Date format is DD-MMM-YYYY (01-Jan-2020). If the exact date is unknown, please enter any known part of the date (e.g. year).

I cannot recall the date

How was this test performed?

Nose or throat swab
Blood test
Other

What were the results of your COVID-19 test?

At least one of my tests was positive
Waiting for test results
None of my tests were positive
Unknown

How do you feel physically right now?

I feel physically normal
I'm not feeling quite right

Do you have any of these symptoms right now?
Please tick all that apply

Have you been told by your doctor that you should be shielding and not to go out?

Yes

Do not know

How many weeks or months have you been shielding and not gone out?

Days
Weeks
Months

ABOUT YOUR ALLERGIES:

Do you have allergies to any of the following, whether you have been diagnosed or not?

(Please select all that apply)

Grass
(Includes grass pollen from various types of grass such as Bermuda, Rye, Orchard, Kentucky, Sweet vernal, Timothy, etc.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Weed
(Includes weed pollen from various types of weed plants such as Ragweed, Nettle, Mugwort, Oilseed Rape, Russian Thistle, Rough Pigweed, Dock, etc.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Trees
(Includes tree pollen from various types of trees such as Beech, Ash, Alder, Birch, Cedar,Box elder, Cottonwood, etc.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Mould
(Includes various species of fungal moulds that can grow on foods and damp places. Some examples of such moulds are Alternaria, Aspergillus, Cladosporium and Penicillium, Rhizopus, etc.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Food
(Includes foods such as milk, eggs, peanuts, tree nuts, fish, shellfish, some fruit, and vegetables, etc.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Dustmite
(Includes house dust mites that are tiny insects found in association with dust in dwellings and items such as bedding, and carpeting.)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Cat Hair
(Includes cat dander (dead skin), fur as well as other elements such as cat feces and urine)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Dog Hair
(Includes dog dander (dead skin), fur as well as other elements such as dog feces and urine)

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

Others, please specify:

Yes: Skin test
Yes: Blood test
Yes: Skin and blood test
Yes: Symptoms only
No

SPT:
Grass Trees Weed Mould Food Dust Mite Cat Hair Dog Hair Other

SAT:
Dust Mite Grass Cat Hair Mould Dog Hair Other

SPT:
SAT:

ADDITIONAL QUESTIONS ABOUT YOUR ASTHMA MEDICATIONS:

Are you taking any of the asthma medications below?
(Please select all that apply)

Clenil Modulite MDI

QVAR MDI

Qvar_Easi-Breathe

QVAR Autohaler

Flixotide Accuhaler

Flixotide MDI

Pulmicort Turbohaler

Seretide Accuhaler

Seretide MDI

Airflusal Forspiro

Sirdupla MDI

Symbicort Turbohaler

Symbicort MDI

DuoResp Spiromax

Aerivio Spiromax

Fostair MDI

Fostair NEXThaler

Flutiform MDI

Relvar Ellipta

Serevent Accuhaler

Serevent MDI

Oxis Turbohaler

Onbrez Breezhaler

Striverdi Respimat

Formoterol Easyhaler

Seebri Breezhaler

Spiriva Handihaler

Spiriva Respimat

Braltus Zondat

Eklira Genuair

Incruse Ellipta

Duaklir Genuair

Anoro_Ellipta

Ultibro Breezehaler

Spiolto Respimat

Trelegy Ellipta

Trimbow MDI

During the last 7 days, how many times did you forget to take your usual asthma medication?
- This includes all other medication you may be taking to manage your asthma symptoms. E.g.: Reliever and/or Preventer inhalers, oral corticosteroid tablets, etc.)

All the time
More than half the time
Approximately half the time
Less than half the time
None

SMOKING STATUS:

Which best describes your smoking status now?

Still smoking

Used to smoke, but not now

Never Smoked

If you are still smoking:

How many cigarettes do you smoke per day?

per day

How many years have you been smoking?

years

If you used to smoke:

How many cigarettes did you smoke per day?

per day

How old were you when you started smoking regularly?

years old

How old were you when you stopped smoking regularly?

years old

YOUR HEIGHT AND WEIGHT:

What is your height?
chose EITHER metric or Imperial

Metric (m)

Imperial (ft/in)

What is your current height:

(m)

What is your current height:

(ft) (in)

What is your weight?
chose EITHER metric or Imperial

Metric (kg)

Imperial (lbs)

What is your current weight:

(kg)

What is your current weight:

(lbs)

OPTIONAL QUESTIONNAIRE:

Nijmegen Questionnaire:

These questions will help us understand how well your asthma treatment is working for you.

Please select the number which reflects how often you experience each of the symptoms listed below

Chest pain

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Feeling tense

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Blurred vision

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Dizzy spells

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Feeling confused

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Faster / deeper breathing

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Short of breath

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Tight feelings in chest

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Bloated feeling in stomach

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Tingling fingers

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Unable to breathe deeply

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Stiff fingers or arms

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Tight feelings around mouth

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Cold hands or feet

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Palpitations

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Feelings of anxiety

0 Never
1 Rarely
2 Sometimes
3 Often
4 Very Often

Severe Asthma Questionnaire (SAQ):

These questions will help us understand how severe asthma is affecting your quality of life

Select the number that applies to you:

How difficult is this part of your life during the last two weeks because of your asthma symptoms and the side effects of your medicines?

1 = very, very difficult (worst possible)

2 = very difficult

3 = difficult

4 = moderately difficult

5 = slightly difficult

6 = very slightly difficult (just noticeable)

7 = no problem

1. My social life. For example: visiting friends, walking with friends, talking with friends, going to bars/restaurants, and parties.

1
2
3
4
5
6
7

2. My personal life. For example: washing, dressing, looking after myself, love life.

1
2
3
4
5
6
7

3. My leisure activities. For example: walking for pleasure, sports, exercise, travelling, taking vacations.

1
2
3
4
5
6
7

4. My jobs around the house. For example: housework, shopping, home maintenance, gardening.

1
2
3
4
5
6
7

5. My work or education. For example, missing days, can't do all I want to do.

1
2
3
4
5
6
7

6. My family life - how it affects me. For example: caring for children, family responsibilities.

1
2
3
4
5
6
7

7. My family life - how it affects others. For example: others taking time off work, problems with childcare, family members becoming upset.>

1
2
3
4
5
6
7

8. Depression. For example, feeling sad, fed up, blue.

1
2
3
4
5
6
7

9. Irritable. For example, snap at people, get angrier than I should.

1
2
3
4
5
6
7

10. Anxiety in general. For example, worry about things, always on edge.

1
2
3
4
5
6
7

11. Worry that asthma may get worse. For example, medicines no longer help, more frequent attacks.

1
2
3
4
5
6
7

12. Worry about long term side effects of medicines. For example, worry about cataracts, diabetes, bone fracture.

1
2
3
4
5
6
7

13. Getting tired. For example, feeling tired for no reason, waking in the morning feeling tired.

1
2
3
4
5
6
7

14. Problems at night. For example, difficulty going to sleep, being woken very easily, waking often at night.

1
2
3
4
5
6
7

15. The way I look. For example, my weight, my skin bruises easily, using medicines in public, other people judging me.

1
2
3
4
5
6
7

16. Problems with food. For example, I find I get very hungry, I just can't stop eating, stomach problems (e.g., pain, bloating, etc.)

1
2
3
4
5
6
7

Use the scale on this scale to rate your OVERALL quality of life due to ASTHMA SYMPTOMS and the SIDE EFFECTS of your medicines.

100: Perfect quality of life

95: Nearly Perfect quality of life

90:

85: Very good quality of life

80:

75:

70: Good quality of life

65:

60-55: Moderately good quality of life

50:

45:

40: Somewhat bad quality of life

35:

30-25: Bad quality of life

20:

15: Very bad quality of life

10:

5: Extremely bad quality of life

0: No quality of life

1. During the last TWO WEEKS, my quality of life has been

write a number

2. During the month of the year when my asthma is at its BEST, My quality of life has been

write a number

3. During the month of the year when my asthma is at its WORST, My quality of life has been

write a number

Rhinitis Control Assessment Questionnaire (RCAT)

This questionnaire will help us understand how your rhinitis is affecting your quality of life.
(please skip this questionnaire if this does not apply to you).

Please select the category that best describes how frequently you experience each of the symptoms below.

1. During the past WEEK, how often did you have nasal congestion?

Never
Rarely
Sometimes
Often
Extremely Often

2. During the past WEEK, how often did you sneeze?

Never
Rarely
Sometimes
Often
Extremely Often

3. During the past WEEK, how often did you have watery eyes?

Never
Rarely
Sometimes
Often
Extremely Often

4. During the past WEEK, to what extent did your nasal or other allergy symptoms interfere with your sleep?

Never
Rarely
Sometimes
Often
Extremely Often

5. During the past WEEK, how often did you AVOID any activity (for example, gardening, exercising, visiting a house with a dog or cat) because of your nasal or other allergy symptoms?

Never
Rarely
Sometimes
Often
Extremely Often

Gastroesophageal Disease Questionnaire (GERD-Q)

This questionnaire is for patients with upper gastrointestinal symptoms.
(please skip if this does not apply to you)

Important: To answer this questionnaire, take only the last 7 days (1 week) into account and answer each question by selecting one response per question.

In the last week, how many days did you have a burning feeling behind your breastbone (heartburn)?

Never
1 day
2 to 3 days
Between 4 and 7 days

In the last week, how many days did you have the contents of your stomach (liquid or food) moving upwards to your throat or mouth (regurgitation)?

Never
1 day
2 to 3 days
Between 4 and 7 days

In the last week, How many days did you have pain in the centre of your stomach?

Never
1 day
2 to 3 days
Between 4 and 7 days

In the last week, how many days did you have nausea or felt like throwing up?

Never
1 day
2 to 3 days
Between 4 and 7 days

In the last week, how many nights did you have difficulty getting a good night's sleep because of your heartburn and/or regurgitation?

Never
1 day
2 to 3 days
Between 4 and 7 days

In the last week, how many days did you take medication other than what your doctor ordered for your heartburn and/or regurgitation, other than what the physician told you to take) (such as Tums, Rolaids, Maalox?)

Never
1 day
2 to 3 days
Between 4 and 7 days

Berlin Questionnaire

This questionnaire assesses your breathing patterns during sleep.

CATEGORY 1

1. Do you snore?

Yes
No
Do not know

If you snore:

2. Your snoring is:

Slightly louder than breathing
As loud as talking
Louder than talking
Very loud - can be heard in adjacent rooms

3. How often do you snore?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

4. Has your snoring ever bothered other people?

Yes
No
Don't know

5. Has anyone noticed that you quit breathing during your sleep?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

CATEGORY 2

6. How often do you feel tired or fatigued after your sleep?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

7. During your waking time, do you feel tired, fatigued or not up to par?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

8. Have you ever nodded off or fallen asleep while driving a vehicle?

Yes
No

If yes:

9. How often does this occur?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

CATEGORY 3

10. Do you have high blood pressure?

Yes
No
Don't know

Vocal Cord Dysfunction Questionnaire (VCDQ)

This questionnaire assesses symptoms in patients with a diagnosis of Vocal Cord Dysfunction (please skip if this does not apply to you).

Please select the response that indicates how much you agree with each statement.

1. My symptoms are confined to my throat / upper chest.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

2. I feel like I can't get breath past a certain point in my throat / upper chest because of restriction.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

3. My breathlessness is usually worse when breathing in.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

4. My attacks typically come on very suddenly.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

5. I feel that there is something in my throat that I can't clear.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

6. My attacks are associated with changes in my voice.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

7. My breathing can be noisy during attacks.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

8. I'm aware of other specific triggers that cause attacks.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

9. My symptoms are associated with an ache or itch in my throat.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

10. I am frustrated that my symptoms have not been understood correctly.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

11. I am unable to tolerate any light pressure around the neck eg tight clothes or bending the neck

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

12. The attacks impact on my social life.

Disagree strongly
Disagree
Neither agree nor disagree
Agree
Agree strongly

Generalised Anxiety Disorder Questionnaire (GAD-7)

This questionnaire is used to assess severity of generalised anxiety disorder
(please skip if this does not apply to you).

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious or on edge?

Not at all
Several days
More than half the days
Nearly every day

Not being able to stop or control worrying?

Not at all
Several days
More than half the days
Nearly every day

Worrying too much about different things?

Not at all
Several days
More than half the days
Nearly every day

Trouble relaxing?

Not at all
Several days
More than half the days
Nearly every day

Being so restless that it is hard to sit still?

Not at all
Several days
More than half the days
Nearly every day

Becoming easily annoyed or irritable?

Not at all
Several days
More than half the days
Nearly every day

Feeling afraid as if something awful might happen?

Not at all
Several days
More than half the days
Nearly every day

Patient Health Questionnaire (PHQ-9)

This questionnaire is used used to monitor the severity of depression and response to treatment.
(please skip if this does not apply to you).

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things?

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless?

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy?

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating?

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself - or that you are a failure or have let yourself or your family down?

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all
Several days
More than half the days
Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead, or of hurting yourself in some way?

Not at all
Several days
More than half the days
Nearly every day

DB INFORMATION

YOUR ASTHMA HISTORY:

YOUR ASTHMA CONTROL

CONDITIONS RELATERD TO ASTHMA

OTHER CONDITIONS

COVID19

ALLERGENS

ABOUT YOUR ASTHMA MEDICATION

ADDITIONAL MEDICATION FOR ASTHMA MEDICATION

CANCER

SMOKE

Height

Weight:

Nij

saq

rcat

gerd

berlin

hadq

vcdq

gad7

phq9

BACK

BACK_yah

BACK_yasac

CONDITIONS RELATED TO ASTHMA

OTHER CONDITIONS:

covid

allergies

ayam

aqaam

cancer

smoke

height

nijmegen

saq

rcat

gerd

berlin

vcdq

gad7

phq9

Asthma Questionnaire

YOUR ASTHMA HISTORY:

First visit: In the last 12 months:

YOUR ASTHMA SYMPTOMS AND CONTROL:

Think back to the last 4 weeks (28 days).

Please tell us about your asthma symptoms in a typical week within these last 4 weeks (28 days).

Please select the relevant number from 0 to 7

ABOUT YOUR ASTHMA MEDICATION:

CONDITIONS RELATED TO ASTHMA:

Please indicate if you have previously had or currently have any of the following conditions:

OTHER CONDITIONS:

Do you currently have, or have you ever had any of the following health problems or conditions?

You could have been told by your physician to have these conditions or may have received/currently be receiving treatment for these conditions. If so, please select "Yes".

Over the last 2 weeks, how often have you been bothered by the following problems?

CANCER:

ABOUT COVID-19:

Please tell us about how COVID-19 has affected you

ABOUT YOUR ALLERGIES:

Do you have allergies to any of the following, whether you have been diagnosed or not?

ADDITIONAL QUESTIONS ABOUT YOUR ASTHMA MEDICATIONS:

SMOKING STATUS:

If you are still smoking:

If you used to smoke:

YOUR HEIGHT AND WEIGHT:

OPTIONAL QUESTIONNAIRE:

These questions will help us understand how well your asthma treatment is working for you.

Please select the number which reflects how often you experience each of the symptoms listed below

These questions will help us understand how severe asthma is affecting your quality of life

Select the number that applies to you:

How difficult is this part of your life during the last two weeks because of your asthma symptoms and the side effects of your medicines?

1 = very, very difficult (worst possible)

2 = very difficult

3 = difficult

4 = moderately difficult

5 = slightly difficult

6 = very slightly difficult (just noticeable)

7 = no problem

Use the scale on this scale to rate your OVERALL quality of life due to ASTHMA SYMPTOMS and the SIDE EFFECTS of your medicines.

This questionnaire will help us understand how your rhinitis is affecting your quality of life. (please skip this questionnaire if this does not apply to you).

Please select the category that best describes how frequently you experience each of the symptoms below.

This questionnaire is for patients with upper gastrointestinal symptoms. (please skip if this does not apply to you)

Important: To answer this questionnaire, take only the last 7 days (1 week) into account and answer each question by selecting one response per question.

This questionnaire assesses your breathing patterns during sleep.

CATEGORY 1

If you snore:

CATEGORY 2

If yes:

CATEGORY 3

This questionnaire assesses symptoms in patients with a diagnosis of Vocal Cord Dysfunction (please skip if this does not apply to you).

Please select the response that indicates how much you agree with each statement.

This questionnaire is used to assess severity of generalised anxiety disorder (please skip if this does not apply to you).

Over the last 2 weeks, how often have you been bothered by any of the following problems?

This questionnaire is used used to monitor the severity of depression and response to treatment. (please skip if this does not apply to you).

Over the last 2 weeks, how often have you been bothered by any of the following problems?

This questionnaire will help us understand how your rhinitis is affecting your quality of life.
(please skip this questionnaire if this does not apply to you).

This questionnaire is for patients with upper gastrointestinal symptoms.
(please skip if this does not apply to you)

This questionnaire is used to assess severity of generalised anxiety disorder
(please skip if this does not apply to you).

This questionnaire is used used to monitor the severity of depression and response to treatment.
(please skip if this does not apply to you).