I Am Boy / Girl, ____ Years Old and My Height Is___ Cm and My Weight Is ___ Kg

QUESTIONNAIRE FOR CHILD

I am boy / girl, ____ years old and my height is___ cm and my weight is ___ kg.

/make round correct choice and fill empty square/

1. Did you have cough or feel of wheezing or chest tighteness, during last year ?

YES NO

If it’s YES had it be during: efforts, laugh/concern, climatic conditions,

night or some season ? /make round correct choice/

2. Did you have itch, sneeze, clear runny nose or nasal congestion, during last year ?

YES NO

3. Did you be treated because asthma, until now ?

YES NO

It it’s YES, how long it was? ______

4. Did you be treated becuase allergic rhinitis, until now ?

YES NO

5. Did you use some spray or medicine for asthma and /or allergic rhinitis, during last year?

YES NO

Organizer: Pediatric Clinic, Clinical Center, Kragujevac, SERBIA, www.kc-kg.rs

Organizator: Pedijatrijska klinika, Klinicki centar, Kragujevac, SRBIJA, www.kc-kg.rs