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1 COAST III Childhood Origins of ASThma Asthma Allergy Symptoms COAST 3 year visit Subject ID Subject ID: Subject Initials Date completed Interviewer Person answering questions 99. This form was completed by family 1 Yes 2 No 4/2007 Wheezing / Asthma/ Cough Symptoms 1. Has your child had wheezing, shortness of breath, or chest tightness in the past year? (If no, go to question 3) 1a. When was the most recent episode? 1 7 days ago days ago days ago months ago months ago months ago 1b. How many separate episodes in the past year? 1 1 episode 2 2 episodes 3 3 episode 4 > 4 episodes 1c. If there has been an episode during the past one month, how often has your child had wheezing, shortness of breath, or chest tightness? 99 N/A Daytime Nighttime 1 not during the day 7 not during the night 2 monthly 8 <2x / month 3 weekly 9 >2 nights / month 4 < 2x / week 10 > 1 night / week 5 >2x / week 11 Frequent 6 daily 1d. In general, during the past month, how bothered was your child by his/her asthma/wheezing? 1 N/A 2 Not bothered at all 3 Hardly bothered at all 4 Bothered 5 Very bothered 2. Does your child wheeze during a particular season or time of year? 3 don t know 2a. If yes, which season(s) or time of year? 1 spring 1

2 3. Has your child had a cough that you treated with albuterol separate from wheezing in the past year? (If no to 1 and 3, go to ## 8) 3a. When was the most recent episode? 1 7 days ago days ago days ago months ago months ago months ago 3b. How many separate episodes? 1 1 episode 2 2 episodes 3 3 episode 4 > 4 episodes 3c. If there has been an episode during the past one month, how often has your child had a cough treated with albuterol? 99 N/A Daytime Midnight to 6am 1 not during the day 7 not during the night 2 monthly 8 <2x / month 3 weekly 9 >2 nights / month 4 < 2x / week 10 >1 night / week 5 >2x / week 11 Frequent 6 daily 3d. In general during the past month, how bothered was your child by his/her asthma/coughing? 1 N/A 2 Not bothered at all 3 Hardly bothered at all 4 Bothered 5 Very bothered 4. Does your child have a cough during a particular season or time of year? 3 don t know 4a. If yes, which season(s) or time of year? 1 spring 2

3 Asthma/Wheeze/Cough Triggers (Please check only one response for each question below) 5. Is the child s wheezing or coughing symptoms (sx) provoked by: Never causes sx Occasionally causes sx Frequently causes sx Subject ID Always or almost always causes sx a. Respiratory infections? b. Exposure to spring and/or fall pollens? c. Exposure to house dust? d. Exposure to animals? e. Exposure to damp, musty area? (e.g. basement) f. Exposure to tobacco smoke? g. Exposure to chemicals? (e.g. perfume, cleaners) h. Exercise/play? i. Exposure to a change in the weather? j. Exposure to cold air? k. Emotional factors (e.g. stress, crying, laughing)? l. Food? m. Aspirin? Treatment for Asthma Symptoms 6. Has your child taken albuterol for wheezing episodes in the past year? 7. Has your child taken albuterol for coughing episodes in the past year? Don t know 8. Does your child take asthma medicine on a daily basis for wheezing or coughing symptoms at any (If yes to either 6, 7, or 8 enter box. If no go to ## 15) 9. Does your child take asthma medicines during a specific season(s) or time of year to manage wheezing/coughing symptoms? 9a. If yes, which season(s) or time of year? 1 spring 10. If your child is taking daily medication for asthma, how often does your child have symptoms in spite of medicine? 1 monthly 2 weekly 3 < 2x / week 4 >2x / weekly 5 daily 11. Does your child take allergy medication to manage asthma symptoms? 12. Do you pre-treat your child with albuterol (asthma medication) to prevent wheezing or coughing episodes? 1 yes 2 No 12a. If yes, for which reason(s) do you pre-treat? 1 activity or exercise 2 irritants (including cold air) 3 allergens 4 other 3

4 13. Does your child have a step-up plan beyond albuterol as an asthma action plan? 13a. Have you used a step up plan or stepped up your child s asthma medicine in the past 12 months? 13b. If yes, how many times? > What first symptom(s) begins your child s step up plan? 1 runny nose 4 sore throat 2 cough 5 shortness of breath 3 wheeze 6 other 15. Has your child seen a physician for treatment of respiratory problems in the past 12 months? 1 yes 2 No 15a. If yes, how many times 16. Has your child been to Urgent Care or the Emergency Department for treatment of respiratory, coughing or wheezing problems in the past year? 16a. If yes, how many times 17. Has your child been hospitalized for treatment of Respiratory problems in the past year? 17a. If yes, how many times Allergy Symptoms 18. Does your child have an itchy and/or runny nose, frequent sneezing, or nose symptoms like congestion that you associate with allergies (routinely/seasonally)? 18a. If yes, how would you generally describe these symptoms during the past 12 months? 1 Mild 2 Moderate 3 Severe 19.Does your child have itchy and/or watery eyes or eye symptoms that you associate with allergies (routinely/seasonally)? 19a. If yes, how would you generally describe these symptoms during the past 12 months? 1 Mild 2 Moderate 3 Severe 20. If yes to 18 or 19, in general, during the past month, how bothered was the child by his/her allergies? 1 Does not have allergies(go To ## 31) 2 Not bothered at all 3 Hardly bothered at all 4 Bothered 5 Very bothered 4 Deleted: I

5 21. In the past year, has your child had a test for allergies at a medical center other than COAST? 21a. Skin test? 21b. Blood test for allergy sensitization? If yes to 21a or 21b, were there any positive reactions? 21c. Skin test? 3 n/a 21d. Blood test for allergy sensitization? 3 n/a Allergy Triggers (Please check only one response for each question below) 22. Are the child s allergy symptoms (sx) provoked by: Never causes sx causes sx Don t know a. Exposure to spring and/or fall pollens? b. Exposure to house dust? c. Exposure to animals? d. Exposure to damp, musty areas? (e.g. basement) e. Exposure to tobacco smoke? f. Exposure to chemicals? (e.g. perfume, cleaners) g. Food? h. Medicines? i. Insect stings? If yes, complete food allergy?naire Treatment for Allergy symptoms 23. Has your child been given over the counter medication for allergies during the past 12 months? 2 n/a 24. Has your child been prescribed daily medication for allergies during the past 12 months? 2 n/a 25. Is your child prescribed medication for allergies during a specific season(s) or time of year to manage allergy symptoms? 2 n/a 25a. If yes, which season(s) or time of year 1 spring If your child takes allergy medicines 26. During the past 12 months, how frequently has your child used antihistamines and/or decongestants to treat the nose, eyes, or sinus symptoms (prescription and/or over the counter)? (May check one option from each side if both apply) takes medicine daily Comment: No means - has allergies but takes no medicines, n/a means that they do not have allergies so this question does not apply. Formatted: Font: Not Italic As needed 1 Almost every day 2 2-5x/week, but not daily 3 Several times/week but not every wk 4 Several times during past year 5 Never If used seasonally 6 Almost every day 7 2-5x/week, but not daily 8 Several times/week but not every wk 9 Several times during the season 10 Never 5

6 27. During the past 12 months, how frequently has the child used nasal steroids to treat nose, eye, or sinus symptoms? (May check one option from each side if both apply) ) takes nasal steroids daily As needed If used seasonally 1 Almost every day 2 2-5x/week, but not daily 3 Several times/week but not every wk 4 Several times during past year 5 Never 6 Almost every day 7 2-5x/week, but not daily 8 Several times/week but not every wk 9 Several times during the season 10 Never Deleted: 28. If your child is taking medicine for allergy symptoms, how often does your child have symptoms in spite of medicine? 1 Daily and/or nightly 2 Symptoms not daily/nightly but > 1x/week 3 Symptoms < 1x / wk 4 Symptoms < 1x / month 5 Occasionally, not routinely 29. Do you pre-treat your child with allergy/antihistamine medication to prevent allergy symptoms? 29a. If yes, for which reason(s) do you pre-treat? 1 pets 2 irritants (including cold air) 3 other 30. During the past 12 months, how many times has the child had allergy symptoms that required treatment with an oral steroid? (Ex. Prednisone, prednisolone) (Enter 00 if none) Sinusitis 31. During the past 12 months, how many times have you contacted or visited a doctor because of problems with the child s nose, eyes, or sinuses? (Enter 00 if none) Deleted: <sp> Deleted: <sp> 32. During the past 12 months, how many times has the child had a sinus infection that required treatment with antibiotics? (Enter 00 if none) Eczema 33. Has your child had eczema or atopic dermatitis in the past 12 months? 33a. Does your child have eczema or atopic dermatitis now? (If yes to 33 or 33a enter box) 34. Does your child have a treatment regimen for their eczema/atopic dermatitis? 34a. If yes, how many times have you used this step-up plan in the past 12 months? times times 3 2 times/month 4 Continuously 6

7 34b. If yes, how many times have you used this step up plan in the past month? 1 Not routinely 2 4 times / month 3 Weekly 4 Several times/week 5 Daily and/or nightly 35. Which parts of your child s body were affected by eczema during the past 12 months? 35a. Head 1 Yes 2 No 35b. Arms/Hands 1 Yes 2 No 35c. Trunk (mid-section or torso) 1 Yes 2 No 35d. Legs/Feet 1 Yes 2 No 35e. Other 1 Yes 2 No 36. How would you describe your child s worst case of eczema in the last year? (Check one box only) 1 Mild 2 Moderate 3 Severe Food Allergies 37. Is your child allergic to foods? 1 Yes 2 No Other 37a. Are there any foods that you restrict from your child s diet? 1 Yes 2 No (If yes to 37 or 37a, please complete Food Allergy Questionnaire) 38. Has your child been diagnosed with any of the following in the past year? 99 No a. 1 Yes 2 No Otitis Media b. 1 Yes 2 No Sinusitis/sinus infection c. 1 Yes 2 No Hives - cause? d. 1 Yes 2 No Other - Skin e. 1 Yes 2 No Other - Respiratory f. 1 Yes 2 No Other - Stomach/GI g. 1 Yes 2 No Other Eye h. 1 Yes 2 No Other Ear, Nose, Throat i. 1 Yes 2 No Sugeries or procedures j. 1 Yes 2 No Emergency/Urgent Care visits k. 1 Yes 2 No Hospitalizations or illnesses l. 1 Yes 2 No Other m. 1 Yes 2 No Other n. 1 Yes 2 No Other 7

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