Screening Questionnaire

Take a moment to complete the following questionnaire related to your child’s breathing.  These questions are to help recognize if your child is having asthma symptoms. Undiagnosed or under-treated asthma can cause long-term lung problems for your child.

1. Does your child cough or wheeze more than a couple of times per week?
   YES      NO
2. Does your child cough in their sleep more than a couple of times per month?
   YES      NO
3. Does your child cough or wheeze during or after exercise?
   YES      NO
4. Is your child missing school frequently because of problems like coughing or wheezing?
   YES      NO
5. If you have been told that your child has asthma, is rescue medication such as Xopenex or Albuterol being used more than two times per week for flare-ups of coughing or wheezing?
   YES      NO

If you answered “yes” to two or more of the questions above, as recommended by the National Institutes of Health, your child may benefit from having an evaluation by an asthma specialist.

For more information, please discuss your child’s health with his or her primary care physician and call the Asthma Center at UPMC Children's Hospital of Pittsburgh at 412-692-LUNG (5864).