This one-page asthma questionnaire can be completed by the patient before a visit to the physician's office or used for case management of high-risk asthma patients. This tool is available in English and Spanish and can be printed in black and white or color.
This tool contains 12 questions on topics such as overall rating of condition, activity limitations, symptoms, hospital visits/stays, and medications. The patient is also asked to indicate his or her interest in receiving additional information on specific asthma-related topics.
Oregon Department of Human Services, Oregon Asthma Program
Centers for Disease Control and Prevention
Disease/Condition-Related; Quality improvement strategies
Last updated: April 14, 2008.
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