Asthma Questionnaire 2 (Allergic Asthma)
Please answer Yes or No for each answer.
If you have been diagnosed with asthma, please skip to Question #3
1. Do/did either of your parents have asthma?
YES or NO
2. Do/did either of your parents suffer from allergies?
YES or NO
3. Have you experienced any of the following symptoms: sudden or repeated coughing, wheezing, shortness of breath, rapid breathing, and/or tightness in the chest?
YES or NO
4. Does being near the following allergens trigger or worsen your asthma symptoms: dust, pollen from trees or flowers, animal fur or dander, molds, certain foods or other allergens?
YES or NO
5. Do your asthma symptoms seem to be worse during the spring and/or fall?
YES or NO
6. Do you suffer, at any time of the year, from any of the following allergy symptoms: sneezing, itchy/watery eyes, stuffy nose/congestion lasting more than 10 days, runny nose lasting more than 10 days?
YES or NO
Yes to #3 and any other question indicates possibility of asthma or allergic asthma. Questions are from the American Academy of Allergy Asthma & Immunology www.aaaai.org