Perception of Asthma Control in Bermuda
Thank you for taking our ‘Perception of Asthma Control in Bermuda’ Survey, this should take less than 5 minutes to complete.
Whom are you representing doing this survey? *
Do you consider your asthma is ...? *
Age *
Gender *
Race *
Employment Status *
Health Insurance *
Was your asthma diagnosed by a doctor? *
Have you had asthma since childhood? *
When you have asthma do you ...? *
(tick all that apply)
Required
In the past week have you ...? *
(tick all that apply)
Required
Have you had a review of your asthma with your Doctor in the past year? *
Do you have an Asthma Action Plan? *
Do you use a spacer device? *
Have you had your inhaler technique checked by a health professional in the past year? *
Do you have a peak flow meter? *
Have you ever had one-on-one asthma education with an asthma nurse? *
Which treatment do you take for asthma? and how often?
Daily
More than twice a week
Only occasionally
Only when I have a cold /virus
Only when I have asthma symptoms
Never
Rescue/reliever only (Ventolin or Airomir)
Single drug preventer (Beclomethazone, Becotide, Qvar, Flixotide)
Combination inhaler (Symbicort, Seretide / Advair, Dulera)
Singulair
If you do not use prevention daily - Why?
(tick all that apply)
How many times have you been to Emergency (or the Lamb Foggo Acute Care facility) for asthma in the past year? *
How many times have you been admitted to the hospital for asthma in the past year? *
How much time off work/school have you taken due to asthma this past year? (approximately) *
Where do you seek information about asthma? *
(tick all that apply)
Required
Optional EMAIL ADDRESS - if provided we will forward YOUR results and applicable information regarding control.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service