Asthma Essentials Asthma Essentials Checklist - Person with asthma Please answer the questions to the best of your knowledge and based on your current circumstances. Step 1 of 14 7% Welcome! Thank you for taking some time to complete the Asthma Essentials Checklist – you will only need about 10 minutes or so to go through it. The Checklist contains a series of questions about how you may be looking after your asthma or the asthma in someone that you care for. Your response to the questions helps to identify how you may be managing asthma currently and areas in which you could improve or take additional steps. Once you complete the Asthma Essentials Checklist, we will send you information and next steps that best suit your needs. HiddenToday's Date(Required) DD dash MM dash YYYY About You Please complete the below details about yourselfFirst Name(Required) Last Name(Required) Email(Required) If you do not have an email address, please call 1800 ASTHMA (1800 278 462) and one of our Asthma Educators can take you through the Checklist.Year of birth(Required)GenderMaleFemalePrefer not to answerNon-binaryI use a different term/otherState(Required)ACTNSWNTQLDSATASWASuburb(Required) Postcode(Required) ASTHMA DIAGNOSIS AND SYMPTOMS Asthma symptoms are the signs, effects or feelings that you may notice as a result of having asthma. Common symptoms include: Wheeze Cough Shortness of breath Tight chest Q1. Do you think you have asthma or asthma like symptoms?(Required) Yes No I'm undergoing diagnosis Unsure ASTHMA ACTION PLANS An Asthma Action Plan is like an instruction manual for your asthma that is written by your doctor. Everyone with asthma should have an Asthma Action Plan, no matter how old you are or how mild your asthma might feel. It includes day to day steps on managing your asthma and what to do if you do have a flare-up or asthma attack. Q2. Do you have an Asthma Action Plan?(Required) Yes No Unsure RELIEVER USE Relievers are fast-acting medicine that quickly relieve asthma symptoms like coughing, wheezing, being short of breath and a tight chest. They help to relax the muscles that are squeezing tight around the outside of the airways. Everyone with asthma should always have a reliever medicine handy. It is usually a blue puffer. Reliever medicines could be Airomir, Asmol, Bricanyl, Ventolin or Zempreon. Q3. Do you use a reliever puffer to treat your asthma symptoms?(Required) Yes, I use it 2 days a week or less Yes, I use it more than 2 days a week Yes, I use it multiple times a day No, I don't have one Unsure PREVENTATIVE TREATMENT Preventers play a vital part in your asthma treatment. They help to treat the underlying cause of the symptoms and work by treating the inside of airways to help keep them clear. You usually take preventers every day even when feeling well. Q4. Are you on an asthma preventer medicine?(Required) Yes No Unsure SPACER USE Puffers can be used with a spacer to get more of the medicine into the lungs. In some cases, particularly kids, you may also use a spacer with a mask.Q5. Do you use a spacer device with your puffer(s)?(Required) Yes, all the time Yes, but only sometimes No DEVICE TECHNIQUE Using your asthma inhalers (or devices) the right way helps to ensure you are getting the best possible treatment for your asthma.Q6. Has a health professional checked your technique on all your inhalers?(Required) Yes No Unsure KNOWING WHAT TRIGGERS YOUR SYMPTOMS A trigger is anything that can cause you to have asthma symptoms such as cough, wheeze, shortness of breath or tightening chest. Common triggers include exercise, illness, pollen, dust, smoke, strong smells etc.Q7. Do you know what triggers your asthma flare-ups or attacks?(Required) Yes No ASTHMA REVIEWS An asthma review (or check-up) is a time planned by your doctor to talk about your asthma or asthma like symptoms. It is also a great time to review any asthma medicine or treatment plans.Q8. When did you last speak to your doctor about asthma like symptoms?(Required) In the last 12 months More than 12 months ago Never HOSPITALISATION This may include trips to the emergency department, hospital admissions or overnight stays.Q9. Have you been to hospital due to asthma or asthma like symptoms in the last 12 months?(Required) Yes No ASTHMA FIRST AID STEPS It is important for you and those around you to know Asthma First Aid steps. It could save a life!Q10. Do you know Asthma First Aid or what to do in the case of an emergency?(Required) Yes No KNOWLEDGE AND CONFIDENCE It's important that you and those around you feel confident in what asthma is and how to treat and manage asthma well and feel confident with your plan and what to do in an emergency.Q11. How confident do you feel in managing asthma?(Required) Very confident Somewhat confident Not very confident Not confident at all You've made it to the end of the Asthma Essentials Checklist. Once you hit submit via the button below, please check your inbox for information regarding your responses and next steps. Before you go, we'd love to continue to improve our services for people with asthma, please take a second to share your experience with us. The Asthma Essentials Checklist was easy to complete?(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeThe questions were written in a way that was easy to understand?(Required)Strongly disagreeDisagreeNeutralAgreeStrongly agreeHow was the overall experience and is there anything we could do differently?PhoneThis field is for validation purposes and should be left unchanged.
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