Asthma Intake Form Demographics Question Title * 1. How old are you? (Required.) 5-6 7-8 9-10 11-12 13-14 15-16 17-18 Question Title * 2. What grade are you in? (Required.) 12th grade 11th grade 10th grade 9th grade 8th grade 7th grade 6th grade 5th grade 4th grade 3rd grade 2nd grade 1st grade Question Title * 3. What is your gender? (Required.) Male Female Non-binary Question Title * 4. What is your race/ethnicity? (Required.) White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 5. What language is spoken in your home? (Required.) English Spanish Native American Language Other language Next