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Asthma Questionnaire
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Forms
Asthma Questionnaire
Asthma Questionnaire
Name of Insured
(Required)
Full Name
Date of Birth
(Required)
MM slash DD slash YYYY
1. At what age did your asthma commence?
(Required)
2. Date asthma/reactive airway disease (RAD) diagnosed:
(Required)
3. Type of asthma:
(Required)
Extrinsic (allergic)
Chronic
Intrinsic (late onset)
Bronchial
Exercise Induced
Status Asthmaticus
Other (please explain)
Provide details about Asthma
4. How frequently do these episodes occur?
(Required)
5. Do you receive treatment for these episodes?
(Required)
Yes
No
6. Nature of treatment (bronchodilators, aerosol inhalants, steroid therapy).
(Required)
7. Do you receive treatment only during episodes or is the treatment continuous?
(Required)
8. Is your chest clear between episodes?
(Required)
Yes
No
If No, please provide details.
9. Have you ever experienced any limitation of ability to work or been absent from work as a result of an episode?
(Required)
Yes
No
If “YES”, please state number of days.
10. Has hospitalization been necessary, and if so dates:
(Required)
11. Have you ever had your chest X-rayed or undergone any pulmonary function tests?
(Required)
Yes
No
If Yes, please state date and results
12. Please state any further details you feel may be relevant.
(Required)
Signature of Client
Signature of Client
Date
(Required)
MM slash DD slash YYYY
Date
Δ