Asthma Essentials Checklist - Carers of people with asthma or asthma like symptoms

Please answer the questions to the best of your knowledge and based on your current circumstances.

Step 1 of 15

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 asthma in someone you care for.

Your response to the questions helps to identify how you may be managing their 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 yours and their needs.

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Today's Date(Required)

DD dash MM dash YYYY

Who are you completing the Asthma Essentials Checklist for?(Required)

My child/children who have asthma

My partner/spouse

An adult family member

A friend

About you as the carer

Please complete the below details about yourself

First 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.

State(Required)

Suburb(Required)

Postcode(Required)

About the person you care for

Please enter details below about the person you care for/p>

First Name(Required)

Last Name(Required)

Year of Birth(Required)

Gender

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 the person you care for has asthma or asthma like symptoms?(Required)

Yes

Undergoing diagnosis

Unsure

ASTHMA ACTION PLANS

An Asthma Action Plan is like an instruction manual for asthma that is written by a doctor.

Everyone with asthma should have an Asthma Action Plan, no matter how old they are or how mild their asthma might feel.

It includes day to day steps on managing asthma and what to do if the person has a flare-up or asthma attack. 

Q2. Does the person you care for have an Asthma Action Plan?(Required)

Yes

Unsure

RELIEVER USE

Relievers are fast-acting medicine that quickly relieve asthma symptoms like coughing, wheezing, being short of breath and a tight chest. >P>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. Does the person you care for use a reliever puffer to treat their asthma symptoms?(Required)

Yes, they use it 2 days a week or less

Yes, they use it more than 2 days a week

Yes, they use it multiple times a day

No, they 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 they on an asthma preventer medicine?(Required)

Yes

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 they use a spacer device with their puffer(s)?(Required)

Yes, all the time

Yes, but only sometimes

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 their technique on all inhalers?(Required)

Yes

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 their asthma flare-ups or attacks?(Required)

Yes

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 they last see a 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 they been to hospital due to asthma or asthma like symptoms in the last 12 months?(Required)

Yes

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

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 their 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)

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The questions were written in a way that was easy to understand?(Required)

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How was the overall experience and is there anything we could do differently?

Phone

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