• In the past 7 days I got impatient with other people
• In the past 7 days I was bothered by little things
• In the past 7 days It was hard for my child to play sports or exercise because of asthma.
• In the past 7 days, My child felt overwhelmed.
• In the past 4 weeks, I have to work really hard to pay attention or I make mistakes
• In the past 7 days I have had to work harder than usual to keep track of what I was doing
• In the past 7 days, How many days were you strong enough to pour a drink from a full pitcher or carton?
• <u>Over the past 7 days</u>, how short of breath did you get with each of these activities? Walking up 20 stairs (2 flights) without stopping
• In the past 7 days It was hard for me to have fun
• In general, how would you rate your mental health, including your mood and your ability to think?
• In the past 7 days, I felt unable to manage things in my life.
• In the past 7 days It was hard for my child to run when he/she had pain.
• In the past 7 days My child felt lonely.
• I feel better after smoking a cigarette.
• Smoking stimulates me.
• In the past 7 days, when I was in pain I asked for someone to help me.
• CURRENT level of confidence I can list my medications, including the doses and schedule.
• Are you able to open and close a zipper?
• In the past 7 days, How many days was your child strong enough to carry heavy things with his/her hands?
• In the past 7 days, How many days was your child strong enough to open a jar by himself/herself?