Assessment Form

1. Do you have trouble breathing or coughing when you walk or exert yourself a little?

2. Does weather change affect your allergic symptoms?

3. Do you wake up at night due to cough or breathlessness?

4. Do you use an inhaler?

5. Is there a wheezing sound in your chest?

6. Do your symptoms ever interfere with exercise and daily activities?

7. Do you have breathing difficulty or cough when you climb up?

8. Is mold or mildew(damp walls), a problem at your home?

9. Does your nose get itchy or watering in morning?

10. Do you live near any areas of heavy smog or air pollution?

11. Have you exposed to any chemical, organic dust, etc. at home or work?

12. Does any member of your family have a history of allergy?

13. Do you sneeze a lot when you wake up in morning?

14. Do your eyes get itchy or watering in morning?

15. Have you ever smoked?

16. Does anyone in your home smoke?