AsthmaCommunityNetwork.org

Questionnaires

CHAMPS provides seven questionnaires to help the practice team assess and monitor the patients in the asthma intervention. Each of the questionnaires is described below.

 

Questionnaire Description File Type

Asthma Symptoms & Utilization: Baseline

Documents the patient's recent asthma history, including symptoms, healthcare utilization, and medication use; used to assess a baseline for measuring improvement in asthma over time by comparing to the Asthma Symptoms & Utilization: Follow-up questionnaire

MS Word | PDF

Asthma Symptoms & Utilization: Follow-up

Documents the patient's recent asthma history, including symptoms, healthcare utilization, and medication use; used to asses improvement in asthma over time when compared to the Asthma Symptoms & Utilization: Baseline questionnaire

MS Word | PDF

Child Asthma Risk Assessment Tool (CARAT)

Documents the patient's asthma risk factors; used to generate a personalized asthma risk treatment plan that is tailored to each unique patient

MS Word | PDF

Demographics 

Records basic demographic information on the patient, including gender, age, race, ethnicity, and economic variables; practices routinely collect much of this information separately

MS Word | PDF

Home Environment Observation

Documents the environmental risk factors in a child's home; used to tailor the intervention to each unique patient

MS Word | PDF

Asthma Counselor Checklist

Documents the Asthma Counselor's counseling process at each visit; used to guide counseling visits and track success toward counseling objectives over time

MS Word | PDF

 

Instruction for completing each questionnaire are provided on the individual forms. More information about how to administer questionnaires is provided in the Manual.

 

 

 

 

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