NJ Inhome Asthma Pilot Visit 3

Step 1 of 3 - General information

Participant’s assigned Unique ID*
Interview / Home Visit Date (MM/DD/YYYY)*
MM slash DD slash YYYY
Interviewer’s / CHW’s Initials*
What is your zip code?*
What is your relationship to this child? (e.g. mother/father, grandparent, guardian, other)*
What is your child’s gender?*
How old is your child? __________ years*
Please enter a number from 0 to 50.
Is your child Hispanic or Latino?*
What is your child’s race? (Select all that apply)*
- White
- Black or African American
- Alaska Native or American Indian
- Asian
- Native Hawaiian or other Pacific Islander
- Other (please specify below):
- Decline
Other*
What is the highest grade or level of school YOU have finished?*
- I didn’t go to school
- 8th grade or less
- Some high school but did not graduate
- High School graduate or GED
- Some college / vocational or technical school
- Graduated from college, graduate school
What language(s) do you speak most at home? (Select all that apply)*
- English
- Spanish
- Chinese (Mandarin or Cantonese)
- Portuguese
- Guajarati
- Hindi
- Arabic
- Haitian Creole
- French
- Urdu
- Bengali
- Karen
- Other (please specify below):
Other
Has your child’s doctor or other health professional provided you with a written plan (action plan) to help you decide how to change your child’s asthma medicine in response to changes in his/her asthma?*
- Yes
- No
- I don’t know
If yes, do you have a copy of your child’s current written plan (action plan) that I can see?*
- Yes
- No
[CHW must visually confirm that the caregiver has a copy of the child’s current asthma action plan to check yes]
The last time your child’s asthma got worse, did you use a written plan (action plan) to decide what medicines to use?*
- Yes
- No
- I don’t know
In the past 6 months, how many work or school days have you or another adult caregiver missed because of your child’s asthma? ____________ number of days*
In the past 6 months, how many days of childcare or school has your child missed because of their asthma? ____________ number of days*

Acceptable response: not applicable/child does not go to childcare or school
Has your child received a flu shot in the past 12 months?*
- Yes
- No
- No - child has an egg allergy
- I don’t know
What are the ages of other children that live in the home? Do any of the other children also have asthma?*
Age in Years Asthma

Add a new row for each child by clicking the plus sign to the right of the row.
Including yourself, how many adults (age 18 or older) live in the home? ___________ number of adults*
Please enter a number less than or equal to 30.
How many of the adults (age 18 or older) living in the home also have asthma? ___________ number of adults with asthma*
Please enter a number less than or equal to 30.

Who answered the Asthma Scale?
- Caregiver only
- Caregiver and child
- Child only
Which Asthma Scale used?
- TRACK for under age 4
- ACT for age 4 to 11
- ACT for age 12 and over
During the past 4 weeks, how often was your child bothered by breathing problems, such as wheezing, coughing, or shortness of breath?*
Please enter a number from 0 to 20.
During the past 4 weeks, how often did your child's breathing problems (wheezing, coughing, shortness of breath) wake him or her up at night?*
Please enter a number from 0 to 20.
During the past 4 weeks, to what extent did your child's breathing problems, such as wheezing, coughing, or shortness of breath, interfere with his or her ability to play, go to school, or engage in usual activities that a child should be doing at his or her age?*
Please enter a number from 0 to 20.
During the past 3 months how often did you need to treat your child's breathing problems (wheezing, coughing, shortness of breath) with quick-relief medications (albuterol, Ventolin, Proventil, Maxair, ProAir, Xonepex, or Primatene Mist)?*
Please enter a number from 0 to 20.
During the past 12 months, how often did your child need to take oral corticosteroids (Prednisone, prednisolone, Orapred, Prelone, or Decadron) for breathing problems not controlled by other medications?*
Please enter a number from 0 to 20.
Total
How is your asthma*
Please enter a number from 0 to 3.
How much of a problem is your asthma when you run, exercise or play sports?*
Please enter a number from 0 to 3.
Do you cough because of your asthma*
Please enter a number from 0 to 3.
Do you wake up during the night because of your asthma?*
Please enter a number from 0 to 3.
During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?*
Please enter a number from 0 to 5.
During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?*
Please enter a number from 0 to 5.
During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?*
Please enter a number from 0 to 5.
Total*
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?*
Please enter a number from 0 to 5.
During the past 4 weeks, how often have you had shortness of breath?*
Please enter a number from 0 to 5.
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?*
Please enter a number from 0 to 5.
During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?*
Please enter a number from 0 to 5.
How would you rate your asthma control during the past 4 weeks?*
Please enter a number from 0 to 5.
Total*

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Step 1 of 3 - General information

Caregiver Home Environment Questions

Living Room Walk-Through Observations

Child’s Bedroom Walk Through Observations

Kitchen Walk Through Observations

Bathroom Walk Through Observations

Additional Room 1 Walk Through Observation

Additional Room 2 Walk Through Observation

Age in Years	Asthma