Please answer the following to the best of your ability. Share your story How has asthma affected you? * I have asthma Someone I know has asthma I care for someone with asthma How long ago were you or the person you care for diagnosed with asthma? * In the last 1-3 years 3-5 years 5+ years In general, what would you say your asthma management is? * Excellent Very good Good Fair Poor On a scale of 1 to 10 how much trouble does asthma cause you? 1 being none at all and 10 being extreme. * Enter a number between 1 and 10. How long has it been since you last had any symptoms of asthma? * Never Less than one day ago In the last week In the last month In the last year More than a year ago How long has it been since you last took your asthma medication? * Never Less than one day ago In the last week In the last month In the last year More than a year ago Which of the following were the problems you consulted your doctor about in the last year? (Please tick all that apply) * I went because of symptoms such as coughing or breathlessness I went because I was having an asthma attack I went for my usual consultation None of these apply to me At any time in the last 12 months, was your asthma worse than usual or out of control? * Yes No During the last 4 weeks, how often did you asthma interfere with your daily activities? * None of the time Some of the time Most of the time All of the time Does your asthma limit you in PHYSICAL activities (whether that's exercising or doing moderate activities)? * Not at all A little of the time Some of the time Most of the time All of the time Does your asthma limit you in SOCIAL activities (that is, socialising with friends, seeing your family, going to social gatherings etc)? * Not at all A little of the time Some of the time Most of the time All of the time Does your CURRENT workplace make your asthma worse due to chemicals, smoke, fumes or dust? * Yes No Don't know Not applicable Have any of your PREVIOUS workplaces worsened your asthma due to chemicals, smoke, fumes or dust? * Yes No Don't know Not applicable Do you have a written asthma action plan (as in written instruction of what to do if your asthma gets out of control)? * Yes No Don't know Did your doctor or nurse help you to make sure you could correctly use all of your current types of inhalers before you started using them? * Yes No In the last year, have you had a planned review or check-up of your asthma with your doctor or nurse? * Yes No Does anyone else in your family have asthma? * Yes No Which of the following best describes your home situation? * My home is smoke free People occasionally smoke in the house People frequently smoke in the house Does your home have any pets? * Yes No Have you had to change things in your home due to your asthma (such as using a dehumidifier, air cleaner, purifier or anything else you've had to change)? * Yes No If there are any other additional comments or information you would like to provide please do so here. This section is for if you would like us to contact you to assist you in your asthma management and education. * Yes Not at this time Full name (Optional) Email (Optional) Phone (Optional) Date of birth (dd/mm/yyyy) (Optional) reCAPTCHA Submit
