• In the past 7 days, I had trouble concentrating.
• In the past 7 days I felt scared that I might have trouble breathing because of my asthma.
• In the past 7 days I had trouble sleeping at night because of my asthma.
• In the past 7 days My child had trouble doing schoolwork when he/she had pain.
• When I haven't been able to smoke for a few hours, the craving gets intolerable.
• I crave cigarettes at certain times of day.
• In the past 7 days, when I was in pain I lay down.
• In the past 7 days, How many days did you exercise or play so hard that you felt tired?
• Are you able to write with a pen or pencil?
• In the past 7 days, How many days was your child strong enough to open a heavy door?
• Thinking about the past 4 weeks, My child enjoyed his/her life.
• In the past 7 days I am able to do all of my regular family activities
• In the past 7 days My child got scared really easy.
• In the past 7 days My child worried when he/she went to bed at night.
• In the past 7 days My child worried when he/she was at home.
• In the past 7 days, My child's back hurt.
• In the past 7 days I worried about what could happen to me.
• Considering your shortness of breath <u>over the past 7 days</u>, rate the amount of difficulty you had when doing the following activities: Walking up 20 stairs (2 flights) without stopping
• Considering your shortness of breath <u>over the past 7 days</u>, rate the amount of difficulty you had when doing the following activities: Sweeping or mopping
• Considering your shortness of breath <u>over the past 7 days</u>, rate the amount of difficulty you had when doing the following activities: Carrying something weighing 10-20 lbs (about 4.5-9 kg, like a large bag of groceries) from one room to another