Child Asthma Review (4-11)

If your child (aged 4-11) has asthma and requires a review, please submit this form.

Your healthcare provider can help you take appropriate action to better manage your asthma.

Child Asthma Review

Please use date format: DD/MM/YYYY

How to answer the childhood asthma control test

Let your child answer the first four questions. If your child needs help reading or understanding the question, you may help, but let your child choose select the response.

Complete the remaining three questions on your own without letting your child's response influence your answers. There are no right or wrong answers.

Asthma Control Test

To be answered by the child:

To be completed by the parent/guardian/carer:

If your score is between 0 and 12:

Off target

If your child's score is 12 or less, their asthma may be very poorly controlled. Please contact the practice to arrange a review as early as possible. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 13 and 20:

On target

Your child's asthma may not be as well controlled as it should be. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 21 and 27:

Well done

Your child's asthma control appears to be under control over the last 4 weeks.

However, if your child is experiencing any symptoms or you have any queries, please add them in to the box at the end of this form.

Additional Questions

Please complete the additional questions below and then submit your review.

Additional Questions

Is your child exposed to second hand smoke at home? *
Does your child have a personalised asthma action plan? *
Since your child's last review, have they needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of their asthma? *
Since your child's last review, have they needed a course of steroid tablets to get their asthma under control? *

Inhalers

Please select the types of inhalers that the child uses:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *