Table 1.

Health Care Utilization Questionnaire

This questionnaire is to find out how much you have visited a hospital, ER, doctor’s office, or school clinic because of your asthma in the past 3 months.

During the past 3 months, have you ever been hospitalized because of asthma? Yes No If yes, how many days were you in the hospital? _____________ During the past 3 months, have you ever been taken to the Emergency Room because of asthma? Yes No If yes, how many times? _____________ During the past 3 months, have you ever been seen by the asthma specialist? Yes No If yes, how many times? _____________ During the past 3 months, have you ever been seen by your primary care providers (physician or nurse practitioner) because of worsening asthma? Yes No If yes, how many times? _____________ During the past 3 months, have you ever been seen by your primary care providers (physician or nurse practitioner) for the routine check-up of your asthma? Yes No If yes, how many times? _____________ During the past 3 months, have you ever visited your school clinic because of your asthma symptoms? Yes No If yes, how many times? _____________ During the past 3 months, have you ever missed days of school because of your asthma? Yes No If yes, how many days in total? _____________