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Correlation between asthma and smoking
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Do you have asthma
Yes
No
Clear selection
Do you smoke or have ever smoked
Never smoked
Current smoker
Ex-smoker
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How often do you smoke
1-5 cigarettes a week
5-10 cigarettes a day
> 10 cigarettes a day
Never
Clear selection
Are you ever exposed to second-hand smoke at work, home, school, etc.
Yes
No
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How often are you exposed to second-hand smoke?
Every once and awhile
Often
Everyday
Never
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Do you feel as if smoking or being exposed to second-hand smoke makes your asthma symptoms worse
Yes
No
No asthma or no exposure
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Do you have any other triggers that cause an asthma exacerbation; pollen, pet hair, dander, etc. ( comment below, if none respond n/a)
Your answer
Use the diagram to assess your asthma severity on a normal day when not exposed to irritants
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
No asthma
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Use the diagram to assess your asthma severity when having an exacerbation due to smoking or being exposed to second-hand smoke
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
No asthma
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Do you track your Peak Flow Rate
Yes
No
No asthma
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Do you take any medications or inhaled steroids for your asthma daily (comment below, if none respond n/a)
Your answer
Do you take rescue medications (albuterol) or inhaled steroids for an asthma exacerbation (comment below, if none respond n/a)
Your answer
After completing this survey would you classify your asthma as smoking-induced asthma
Yes
No
No asthma
Clear selection
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