Childhood Asthma Control Test (ACT* - adapted) - FOR CHILDREN 4 - 11 YEARS OLD

This survey is adapted from the ACT^(c) test, which is used to help assess asthma and respiratory control in children between the ages of 4 and 11 years old. In the context of the Breathe Better with Sparky^TM Project, it is being used to establilsh a baseline of respiratory and asthma control for children who enter into the Project. The information is anonymous so we do not see individual results for your child.
*copyright - GlaxoSmithKline

Let your child respond to QUESTIONS 1 - 4. If your child needs help reading or understanding the question, you may help, but let your child select the response. There are no right or wrong answers.

Question Title

* 1. How is your asthma or breathing problem (coughing, wheezing, shortness of breath) today?

Very Bad

Bad

Good

Very Good

Question Title

* 2. How much of a problem is your asthma or breathing problem (coughing, wheezing, shortness of breath) when you run, exercise or play sports?

It's a big problem. I can't do what I want to do

It's a problem and I don't like it

It's a little problem but it's okay

It's not a problem

Question Title

* 3. Do you cough because of your asthma or breathing problems (coughing, wheezing, shortness of breath)?

Yes, all the time

Yes, most of the time

Yes, some of the time

No, none of the time

Question Title

* 4. Do you wake up during the night because of your asthma or breathing problem (coughing, wheezing, shortness of breath)?

Yes, all of the time

Yes, most of the time

Yes, some of the time

No, none of the time

Respond to QUESTIONS 5 - 7 yourself and without letting your child's response influence your answers. There are no right or wrong answers.

Question Title

* 5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms or breathing problems (coughing, wheezing, shortness of breath)?

Not at all

1 - 3 days/month

4 - 10 days/month

11 - 18 days/month

19 - 24 days/month

Every Day

Question Title

* 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma or their breathing problems?

Not at all

1 - 3 days/month

4 - 10 days/month

11 - 18 days/month

19 - 24 days/month

Every Day

Question Title

* 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma or their breathing problem (coughing, wheezing, shortness of breath)?

Not at all

1 - 3 days/month

4 - 10 days/month

11 - 18 days/month

19 - 24 days/month

Every day

The last 3 questions are not scored but also help us to better understand asthma or respiratory control for the group of children entering into the Project. the information is anonymous so we do not see the individual results for you child.

Question Title

* 8. During the past 3 months, how often did you need to treat your child's breathing problems (wheezing, coughing, shortness of breath) with quick-relief medications (eg. albuterol, salbutamol, pirbuterol, levalbuterol, epinephrine mist)

Not at all

Once or twice

Once every week

2 - 3 times a week

4 or more times a week

Question Title

* 9. During the past 12 months, how often did your child need to take oral corticosteroids (prednisone, prednisolone, dexamethasone) for breathing problems not controlled by other medications?

Never

Once

Twice

3 times

4 or more times

Question Title

* 10. During the past 12 months, how often was your child admitted to the Emergency Department or Hospital for breathing problems?

Never

Once

Twice

3 times

4 or more times

Questions 1 - 7 are used to establish an ACT^(c) score which may be used by some healthcare providers to assess your child. We only see pooled information, but if you would like a copy of the original ACT^(c) test that you can use with your healthcare provider, please send an email to info@lung-games.com and we will send you a pdf version.

Question Title

* 11. Is your child participating in the Breathe Better with Sparky^TM Project?

Yes

Childhood Asthma Control Test (ACT* - adapted) - FOR CHILDREN 4 - 11 YEARS OLD

Question Title

* 1. How is your asthma or breathing problem (coughing, wheezing, shortness of breath) today?

Question Title

* 2. How much of a problem is your asthma or breathing problem (coughing, wheezing, shortness of breath) when you run, exercise or play sports?

Question Title

* 3. Do you cough because of your asthma or breathing problems (coughing, wheezing, shortness of breath)?

Question Title

* 4. Do you wake up during the night because of your asthma or breathing problem (coughing, wheezing, shortness of breath)?

Question Title

* 5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms or breathing problems (coughing, wheezing, shortness of breath)?

Question Title

* 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma or their breathing problems?

Question Title

* 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma or their breathing problem (coughing, wheezing, shortness of breath)?

Question Title

* 8. During the past 3 months, how often did you need to treat your child's breathing problems (wheezing, coughing, shortness of breath) with quick-relief medications (eg. albuterol, salbutamol, pirbuterol, levalbuterol, epinephrine mist)

Question Title

* 9. During the past 12 months, how often did your child need to take oral corticosteroids (prednisone, prednisolone, dexamethasone) for breathing problems not controlled by other medications?

Question Title

* 10. During the past 12 months, how often was your child admitted to the Emergency Department or Hospital for breathing problems?

Question Title

* 11. Is your child participating in the Breathe Better with SparkyTM Project?

* 11. Is your child participating in the Breathe Better with Sparky^TM Project?