The National Asthma Council Logo

 

 

Leading the attack against asthma

 Search website
Home About the NAC Strategy Managing Asthma Research Emergency
 

Asthma Adherence - A Guide for Health Professionals
Asthma Management Handbook Asthma Action Plans Spirometry Resources  Other Resources Information Papers Special Topics Professional Development  

Asthma Adherence
Foreword
Preface
Introduction
Section I
Section II
Section III
Questionnaire
Behaviour Change
References
Tips
Content updated Jun 2001
Page updated 23 Jun 2005

Get Adobe Reader

Get Adobe Flash Player

Questionnaire

This questionnaire2 can be printed directly from your browser, however the results may not be reproduced as clearly as presented here. A printer friendly version can be obtained by downloading the questionnaire in Adobe Acrobat PDF format.

 

Yes No Unsure

Part 1 - Beliefs

a) How do you feel about having asthma?
.......................................................................................
.......................................................................................
b) What concerns do you have about your asthma?
.......................................................................................
.......................................................................................
c) Are you concerned about family members having/getting asthma? Yes No Unsure
d) Does asthma affect your lifestyle? Yes No Unsure
e) Are you aware of any effective treatments for asthma? Yes No Unsure
f) Do you think you can do anything to improve control of our asthma? Yes No Unsure

Part 2 - Asthma Self Management

i) Causes of Asthma

a) Do you know what is happening in your airways? Yes No Unsure
b) Do you know what things cause your asthma to get worse? Yes No Unsure
c) Do you know how to avoid things that make your asthma worse? Yes No Unsure
d) Do you smoke? Yes No Unsure

ii) Medications
a) Which relievers do you use?(please circle)
Ventolin / Atrovent / Bricanyl / Asmol
Respolin / Airomir / Theodur / Neulin
 with spacer          without spacer
b) Which preventer do you use? (Please circle)
None / Becotide / Becloforte / Pulmicort 
Flixotide /  Intal (Forte) / Tilade / Respocort 
Prednisolone
with spacer          without spacer
c) Which symptom controller do you use?(Please circle)
Serevent / Oxis  / Foradile
with spacer          without spacer
d) Do you take any other medications for your asthma? 
 If so, what?
.......................................................................................
.......................................................................................
e) Do you know what each of your medications does?  Yes No Unsure
f) How many times, each day, do you usually need
to use your reliever?                                              ______
g) How many times, each day, do you usually use
 your preventer                                                      ______
h) Do you ever forget to take your preventer?            Yes No Unsure
i) How many times a week would you forget to          
take your preventer?                                             ______

iii) Devices / Techniques
a) Do you know how to use your inhalers properly?
(Ask for demonstration)		 Yes No Unsure
b) Do you rinse your mouth after your preventer? Yes No Unsure

iv) Monitoring Asthma

a) Do you know how to control your asthma by looking for:
(i)  low peak flow reading? Yes No Unsure
(ii)  symptoms of worsening asthma? Yes No Unsure
b) Do you have a peak flow meter?  Yes No
c) When do you use your peak flow meter?
...........................................................................................

v) Worsening Asthma / Action Plan

      
a) Do you know when your asthma is getting worse?    Yes No Unsure
b) Do you have a written plan from your doctor? Yes No Unsure
c) Are you confident you can usually manage your asthma 
 symptoms?		 Yes No Unsure
d) Are you confident you can prevent your asthma symptoms from becoming severe? Yes No Unsure
e) Are you confident you know what to do when your asthma becomes worse? Yes No Unsure
 

2. The questionnaire is based on information from The Health Belief Model as described in Clark, N.M., Gotsch, P.H. & Rosenstock, I.P. 1993, Patient, Professional and Public Education on Behavioural Aspects of Asthma: A Review of Strategies for Change and Needed Research, 30(4), pp. 241-55; Kohber, C.I., Davies, S.L. & Bailey, W.C. 1994, How to implement an asthma education program, Clinics in Chest Med, 16(4), pp. 557-65; Gibson, P.C. & Wilson, A.J. 1996, The use of continuous quality improvement methods to implement practice guidelines in asthma, J Qual Clin Practice, 16, pp. 87-102.