Survey

Have you ever had asthma?	Yes No
Was your asthma confirmed by a doctor?	Yes No Don’t Know
Do you still have asthma?	Yes No Don’t Know
Do you have an asthma action plan (written instructions of what to do if your asthma is out of control)?	Yes No
Do you have a home nebuliser for asthma treatment? Interviewer: if “yes” prompt “have you used it in the last 12 months?	Yes No Don’t have a nebuliser
Do you have a peak flow meter at home to measure asthma control? Interviewer: if “yes” prompt “have you used it in the last 12 months?	Yes No Don’t have a peak flow meter
Show Prompt Card 1 What preventive (not reliever) medicine do you use regularly for your asthma?	None Intal Becotide Becloforte Pulmicort Tilade Other (specify)
Show Prompt Card 2 Which of the statements shown on this card do you feel are true of your preventer medication?	Works by relieving narrowed breathing tubes quickly Needs to be used when you feel unwell Works by slowly reducing inflammation in the breathing tubes Must not have the dose changed Don’t know
How often do you awaken during the night with asthma?	Nightly Most nights About twice a week Weekly Monthly Less often than monthly Only at certain times of the year (i.e. seasonal) Never
In the last 12 months have you had any hospital admissions for asthma where you stayed at least one night in hospital?	Yes No
In the last 12 months have you had any days lost from work, school or home duties from asthma?	Yes No
How many days would you estimate?	Days............... Don’t know
Show Prompt Card C3 What would you do if you had a bad attack of asthma and six puffs of your reliever (e.g. ventolin, respolin) had not helped? Which of the statements shown on this card most closely matches what you would be likely to do?	Wait another two hours and take more reliever medication Seek medical advice Take another six puffs of reliever medication and see what happens Call an ambulance Get someone to take you to hospital Do something else (specify)
Show Prompt Card C4 What feelings would you have if you had to get help for a bad attack of asthma? Which of the statements shown on this card most closely match how you would be feeling?	You feel that you have failed You would feel embarrassed You do not want to bother others It is the right thing to do You know you will be OK because of past experience Something else (specify)
Show Prompt Card C5 I am now going to read out a number of statements and show you a card for each of them. Could you please tell me which number from 1 to 5 best reflects the way you feel.	Very comfortable Comfortable Don’t mind Uncomfortable Not comfortable at all Don’t know / Other
Show Prompt Card C6 I am the sort of person who understands all about my asthma	Always Often Sometimes Rarely Never Don’t know / other
Show Prompt Card C7 If I took care of my asthma myself, most of the time, I would........	Manage well Manage sometimes Not manage at all Don’t know / other
Show Prompt Card C8 If I were having a very severe attack of asthma I would feel comfortable about going to a doctor or hospital	Very comfortable Comfortable Don’t mind Uncomfortable Very uncomfortable Don’t know / other
Show Prompt Card C9 Going to see a doctor, to help with my asthma is	Easy and convenient Not easy nor convenient Don’t know / other
Show Prompt Card C10 I have information to use (such as an “Asthma Action Plan” or other instructions) to deal with worsening asthma.	Yes, all I need Some No, none at all Don’t know / other