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BIOGRAPHIC DATA Name (Optional): Address: Age: Birthday: Current Occupation: Gender: Nationality: Civil Status:
Instruction: Check what applies. HISTORY: 1. How old are you when you were diagnosed with asthma? ________________________ 2. How many times does your asthma occur in a month? __ Once __ Twice __ Thrice __ Others: Please Specify _____________ 3. When was the last time you have experienced an asthma attack? ____________________________ 4. Is your asthma? ___Hereditary ___Acquired
*If your asthma is Hereditary answers the questions 5-8. If your asthma is Acquired proceed to question number 9.
5. A. Do you have any known family member or relative who has asthma? ___YES ___NO
B. If yes, from what side of the family is asthma present? ___Father Side ___Mother Side ___Both
6. Do you have any siblings who also have asthma? ___YES ___NO
7. How many in your family has asthma? ___One ___Three ___Two ___Others: Please specify ______________
8. How often do you experience cough and colds in a month? ___Frequently ___Rare ___Sometimes ___Never
9. What factor mostly triggers your asthma attacks? CATEGORY: A. If FOOD, put a check on what applies: 10.What kind of food products triggers your asthma? ___Poultry ___Beef ___Fish ___Pork
___Shrimps and Crabs ___Others: Please specify _________ B. If ENVIRONMENT, answer the questions below: 11. Does your current occupation expose you to airway irritants? ___YES ___NO
12. How often are you exposed to these irritants? ___Frequent ___Rare ___Seldom ___Never
13. Does your current work environment have the following irritants? ___Chemicals ___Chlorine ___Spray paint ___Ammonia
14.During what kind of weather do you usually have asthma? ___Sunny ____Rainy ____Both
15.Do you think that the sudden change of the weather triggers your asthma? ___YES ___NO
C. If POLLENS, answer the questions below: 16. Do you have any allergies to pollens? ___YES ___NO
17.Do you have a Flowering Plant or Tree near your house? ___YES ___NO
D. If INSECTS, answer the questions below: 18.Do you have any allergy to insect bites? __YES __NO
19.What kind of insect usual causes your asthma? ___Bee/Bee Sting ___Cockroach
___Others: Please specify___________ E. If ANIMALS, answer the questions below : 20.Do you have pets in your house? ___YES ___NO
___Others: Please specify _______________ 22. How frequent do you come in contact with them? ___Frequent ___Rare __Seldom __Never
F. If LIFESTYLE, answer the questions below: 23.Do you smoke? ___YES ___NO
24.How many stick/s of cigarette do you usually consume per day? ___One ___Five ____Three ____1 Pack
___Others: Please specify____________ 25. What time do you usually sleep? ___6 PM ___10 PM ___8 PM ___1 AM
___Others: please specify ___________ 26.How many hours do you spend sleeping? ____8 hours ____6 hours ____ 4 hours ____ 1 Hour
____Others: Please specify __________ 27.How frequent do you exercise? ___Regularly ___Seldom
___Rare
___Never
28.What kind of exercise do you do? ___ Jogging ___Swimming ____Walking ____Others: Please specify___________
29.How many hours do you spend for exercise? ___ 1-2 Hours ___ 5-6 Hours ____3-4 Hours ____Others: Specify__________
G. If CHORES, answer the questions below: 30.Do you participate in Households chores? ___YES ___NO
31.Who does your household chores? ___You alone ___Other People ___You and other family member ___Others: Specify_____________
32. What chores do you usually do? ___Dusting ___Cleaning Windows ___Cooking ___Doing Laundry ___Watery Plants ___Sweeping the floor
___Others: Specify______________ 33. How many times do you do dusting in your house? ___Frequent ___Rare ___Seldom ___Never