PUTTING ON AIRS



DEPARTMENT OF HEALTH SERVICESDivision of Public HealthF-01413 (11/2014) STATE OF WISCONSINAsthma Care and Environmental Strategies (ACES) ProgramPOST-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)Which is an asthma trigger?Dust mitesCockroachesBed bugsMoldWhich of these pets may bother a person with asthma?DogCatBirdAll of the aboveWhich is true?a. Smoke does not make asthma worseIf you can smell smoke, it can hurt your lungsCigarette smoke is only bad for the person smokingWhere are dust mites found?BeddingMattressCarpets and RugsAll of the aboveWhere can mold or mildew grow that could trigger an asthma episode?Grout or walls in the bathroom that have black or brown spots on themDamp or wet areas on walls or carpetA dryer not vented to the outsideAll of the aboveAll people with asthma should have a written asthma action plan? FORMCHECKBOX TRUE FORMCHECKBOX FALSEJoe has asthma but is not coughing. Does he still need to take his controller medicine? FORMCHECKBOX YES FORMCHECKBOX NOIf I use my rescue inhaler once a day, my asthma is in good control. FORMCHECKBOX TRUE FORMCHECKBOX FALSEFOR AGENCY USE ONLYClient ID No. FORMTEXT ?????Enrollment No. FORMTEXT ?????Number of Correct Answers FORMTEXT ????? ................
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