This asthma questionnaire asks patients requiring anti-asthmatic tablets about their asthma symptoms and medication usage, including how often they use their inhaler, whether they experience daytime or nighttime symptoms, symptoms during activities or exercise, changes to their asthma medication in the past year, hospital admissions in the past 12 months due to asthma, and courses of oral steroids for asthma in the past 12 months. The patient is asked to answer yes or no to each question.

1. ASTHMA QUESTIONNAIRE FOR PATIENTS REQUIRING ANTI-
ASTHMATIC TABLETS
(To be completed in addition to the Travel Questionnaire)
PATIENT’S NAME SEX
DATE OF BIRTH WEIGHT
1. How oftendoyou use yourblue inhaler?
YES NO
2. Does yourasthma cause any day-time symptoms?
YES NO
3. Does yourasthma cause any nighttime symptoms?
YES NO
4. Do youexperience asthmasymptomswhenyoucarryout activities?
YES NO
5. Do youexperience asthmasymptomswhenyouexercise?
YES NO
6. Has yourdoctor changedyourasthma medicationinthe pastyearto improve yourasthmasymptoms?
YES NO
7. Have youbeenadmittedtohospital inthe past12 monthsas a resultof your asthma?
YES NO
8. Have yourequiredacourse of oral steroidsforyourasthmainthe past12 months?
YES NO
PRESCRIBED BY: ISHIKA CHOUDHARY DATE: 15.03.2020
ADDRESS: ARKA JAIN UNIVERSITY,JAMSHEDPUR