Every evening (for each symptom below) record the number (0.1, 2, or 3) that best matches how you/your child felt in the last 24 hours.
(Please photocopy as required)
| SYMPTOMS | Date | ||||||||||||||
| Sleep disturbance due to asthma | Write number in box | ||||||||||||||
| Slept well last night (no asthma) | 0 | ||||||||||||||
| Slept well but tended to wheeze or cough | 1 | ||||||||||||||
| Woke up twice or more with wheeze or cough | 2 | ||||||||||||||
| Bad night, mostly awake with asthma | 3 | ||||||||||||||
| Cough | Write number in box | ||||||||||||||
| None | 0 | ||||||||||||||
| Occasional | 1 | ||||||||||||||
| Frequent | 2 | ||||||||||||||
| Most of the time | 3 | ||||||||||||||
| Wheeze | Write number in box | ||||||||||||||
| None | 0 | ||||||||||||||
| Mild | 1 | ||||||||||||||
| Moderate | 2 | ||||||||||||||
| Severe | 3 | ||||||||||||||
| SYMPTOMS | Date | ||||||||||||||
| Breathlessness on exertion | Write number in box | ||||||||||||||
| None | 0 | ||||||||||||||
| Mild | 1 | ||||||||||||||
| Moderate | 2 | ||||||||||||||
| Severe | 3 | ||||||||||||||
| Runny, snuffly or blocked nose | Write number in box | ||||||||||||||
| None | 0 | ||||||||||||||
| Mild | 1 | ||||||||||||||
| Moderate | 2 | ||||||||||||||
| Severe | 3 | ||||||||||||||
| Reliever Medication | Record the number of times Reliever medication was used during the last 24 hours. | ||||||||||||||
| 1. 12 midnight to 12 noon | |||||||||||||||
| 2. 12 noon to 12 midnight | |||||||||||||||
'Daily Asthma Symptoms Diary’ developed by Hunter New England kidshealth network
