PUTTING ON AIRS



|DEPARTMENT OF HEALTH SERVICES |STATE OF WISCONSIN |

|Division of Public Health |Asthma Care and Environmental Strategies Program |

|F-01412 (03/2016) | |

|PRE-ASSESSMENT QUESTIONNAIRE |

Name – Client / Child ________________________________________________ Date _______________________

Address ______________________________________________________________________________________

Name - Person completing questionnaire_____________________________________________________________

Relationship to Client____________________________________________________________________________

Many things in our homes can trigger asthma episodes. Please answer the following questions. Your answers will help us in help you.

Please circle or check all that are correct. (There may be more than one correct answer)

1. Which is an asthma trigger?

a. Dust mites

b. Cockroaches

c. Bed bugs

d. Mold

2. Which of these pets may bother a person with asthma?

a. Dog

b. Cat

c. Bird

d. All of the above

3. Which is true?

a. Smoke does not make asthma worse

b. If you can smell smoke, it can hurt your lungs

c. Cigarette smoke is only bad for the person smoking

4. Where are dust mites found?

a. Bedding

b. Mattress

c. Carpets and Rugs

d. All of the above

5. Where can mold or mildew grow that could trigger an asthma episode?

a. Grout or walls in the bathroom that have black or brown spots on them

b. Damp or wet areas on walls or carpet

c. A dryer not vented to the outside

d. All of the above

6. All people with asthma should have a written asthma action plan?

TRUE FALSE

7. Joe has asthma but is not coughing. Does he still need to take his controller medicine?

YES NO

8. If I use my rescue inhaler once a day, my asthma is in good control.

TRUE FALSE

|FOR AGENCY USE ONLY |

|Client ID No. |Enrollment No. |Number of Correct Answers |

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