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 Questionnaire 27.29 Kb

	Yes	No	Unsure
Part 1 - Beliefs
a) How do you feel about having asthma?
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b) What concerns do you have about your asthma?
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c) Are you concerned about family members having/getting asthma?
d) Does asthma affect your lifestyle?
e) Are you aware of any effective treatments for asthma?
f) Do you think you can do anything to improve control of our asthma?
Part 2 - Asthma Self Management
i) Causes of Asthma
a) Do you know what is happening in your airways?
b) Do you know what things cause your asthma to get worse?
c) Do you know how to avoid things that make your asthma worse?
d) Do you smoke?
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?
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e) Do you know what each of your medications does?
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?
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)
b) Do you rinse your mouth after your preventer?
iv) Monitoring Asthma
a) Do you know how to control your asthma by looking for:
(i)  low peak flow reading?
(ii)  symptoms of worsening asthma?
b) Do you have a peak flow meter?
c) When do you use your peak flow meter?
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v) Worsening Asthma / Action Plan
a) Do you know when your asthma is getting worse?
b) Do you have a written plan from your doctor?
c) Are you confident you can usually manage your asthma   symptoms?
d) Are you confident you can prevent your asthma symptoms from becoming severe?
e) Are you confident you know what to do when your asthma becomes worse?

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.

Content updated June 2001