Galant & Lin, M.D.’s Inc. - Asthma Van

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Survey on Risk

Patient-Parent Asthma Questionnaire

Name:

E-Mail:

School:

Grade:

During the last two years has your child had repeated episodes of Asthma?
	Yes No

Does your child have episodes of cough, chest tightness, trouble breathing, or wheezing when playing or exercising?
	Yes No

In the past 4 weeks, has your child had episodes of cough, chest tightness, trouble breathing, or wheezing in the morning or during the day time?
	Yes No

Comments:

Disclaimer: This questionnaire has been validated and may be used only as a screening tool to predict the probability of asthma. The answers to the questions and other information or concerns must be discussed with a primary care provider or asthma specialist before a diagnosis is made.

Galant & Lin, M.D.’s Inc. • 1201 W. La Veta, Ste. 501 • Orange, CA 92868
Phone: 714-771-7994 • Fax: 714-744-4167