Do You Have Asthma?

Coughing or difficulty breathing prevents me from completing daily activities.

• yes
• no

I don't like to exercise because I have problems breathing, or I start coughing while exercising.

• yes
• no

Coughing or shortness of breath interrupts my sleep.

• yes
• no

I miss work or school because of breathing problems.

• yes
• no

I feel short of breath at times.

• yes
• no

I feel tightness in my chest at times.

• yes
• no

When I have difficulty breathing, I sometimes wheeze and make a "whistling" sound.

• yes
• no

I have coughing spells at times.

• yes
• no

Dust, pollen or pets trigger my coughing, wheezing and/or difficulty breathing.

• yes
• no

Breathing is harder in very cold weather.

• yes
• no

Breathing is harder in very hot weather.

• yes
• no

Tobacco smoke, fumes or strong odors make it even more difficult for me to breathe.

• yes
• no

When I develop chest colds, I have a hard time breathing.

• yes
• no