Asthma Initiative of Michigan - Asthma Action Plan Feedback Survey
Please contact info@GetAsthmaHelp.org for more information.

* 1. Which form of the electronic Asthma Action Plan have you used?

Form for infants (0-4 years old)

Form for students (5-18 years old)

Adult form

Approximate number of times used:

* 2. Do you believe the electronic Asthma Action Plan provided by MDHHS is an effective method of communication between patients, parents, adults, healthcare providers and daycare/school personnel in supporting asthma management?

1-Strongly Agree

2-Agree

3-Disagree

4-Strongly Disagree

Comments:

* 3. Do you believe this electronic Asthma Action Plan presents adequate, easily understood information?

1-Strongly Agree

2-Agree

3-Disagree

4-Stongly Agree

Comments:

* 4. Do you believe patients will use/review this electronic Asthma Action Plan?

1-Strongly Agree

2-Agree

3-Disagree

4-Strongly Disagree

Comments:

* 5. How easy or difficult was it to complete the Asthma Action Plan for each patient?

1-Difficult

2-Easy

Comments:

* 6. Approximately how long did it take to complete the Asthma Action Plan for each patient?

0-5 minutes

5-10 minutes

10-15 minutes

15 minutes or more

Comments:

* 7. Were there any features that you did not find useful or relevant?

* 8. What features did you find most useful or relevant?

* 9. Do you have any suggestions for improving the tool?

* 10. Other comments: