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.