UrbanMAAP -- Asthma Survey

Name of your school: City: State:

1. Male    Female



2. Age



3. Race (Check only ONE):
   White    Black    Hispanic    Asian    Native American
   Multi-ethnic   (please specify)    Other   (please specify)



4. What is the zip code where you live?



5. What is the cost of your school lunch? (Check only ONE)
   Free or Reduced Price Full price    I do not eat lunch at school



6. What is the highest level of education completed by either of your parents or guardians who live with you?
   (Check only ONE)
   Some High School    High School   Some College   College   Graduate School    Other



7. Do you have any allergies?
   Yes    No



8. Do you have asthma?
   Yes    No



9. Has a doctor ever told you that you have asthma?
   Yes    No



10. Do any of the family members you live with have asthma?
    Yes    No



11. Do any of the family members you live with have allergies?
    Yes    No



12. How do you get to school? (check only one)
    Walk / School Bus / Car / Public Transport
    Other (please specify )




Only answer the remaining questions if you have asthma.

13. During the past year, how many asthma attacks have you had in?
    
    Fall (Sept., Oct., Nov.):     None    1-5    6-10    More than 10   
    
    Winter (Dec., Jan., Feb.):      None    1-5    6-10    More than 10   
    
    Spring (Mar., Apr., May):      None    1-5    6-10    More than 10   
    
    Summer (June, July, Aug.):      None    1-5    6-10    More than 10   



14. Check the season when your asthma attacks are most frequent? Check N/A if you do not have asthma attacks.
    Fall    Winter    Spring    Summer    N/A



15. Where are you most likely to go for treatment when you have an asthma attack? (Check only ONE)
    Family Doctor Office    Specialist    Hospital Emergency Room
    Neighborhood clinic     School Nurse