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CHAMPS provides seven questionnaires to help the practice team assess and monitor the patients in the asthma intervention. Each of the questionnaires is described below.
Instruction for completing each questionnaire are provided on the individual forms. More information about how to administer questionnaires is provided in the Manual.
Questionnaire Description File Type Asthma Symptoms & Utilization: Baseline Documents the patient's recent asthma history, including symptoms, health care utilization, and medication use; used to assess a baseline for measuring improvement in asthma over time by comparing to the Asthma Symptoms & Utilization: Follow-Up Questionnaire MS Word | PDF Asthma Symptoms & Utilization: Follow-Up Documents the patient's recent asthma history, including symptoms, health care utilization, and medication use; used to assess improvement in asthma over time when compared to the Asthma Symptoms & Utilization: Baseline Questionnaire MS Word | PDF Child Asthma Risk Assessment Tool (CARAT) Documents the patient's asthma risk factors; used to generate a personalized asthma risk treatment plan that is tailored to each unique patient MS Word | PDF Demographics Records basic demographic information on the patient, including gender, age, race, ethnicity, and economic variables; practices routinely collect much of this information separately MS Word | PDF Home Environment Observation Documents the environmental risk factors in a child's home; used to tailor the intervention to each unique patient MS Word | PDF Asthma Counselor Checklist Documents the asthma counselor's counseling process at each visit; used to guide counseling visits and track success toward counseling objectives over time MS Word | PDF -
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The CHAMPS Patient Education Handouts provide concise, visual, take-home information for patients and their families. The handouts correspond to specific Asthma Counseling Modules—the core patient education components of the Asthma Counseling sessions. Instructions for how to implement the Asthma Counseling Modules are provided in the Manual. Handouts are most effective when counselors follow these simple guidelines:
- Explain the information on each handout, making sure the family understands the content, before giving them a copy.
- Share the handouts slowly across multiple visits; attempting to give out multiple handouts at a single visit may lead to information overload.
- Provide only the handouts that are pertinent to their child's unique sensitivities and exposures; giving families all of the handouts, regardless of their child's sensitivities and exposure, is misleading and confusing.
Download individual files below. The full set of handouts in English is available in the Patient Handouts section of the Manual.
Handout Asthma Counseling Module English Spanish What is Asthma? Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word What Happens in the Lungs During an Asthma Attack? Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Asthma Action Plan – Blank Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Asthma Action Plan – Example Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word School Asthma Action Plan Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Allergen Sensitivity Test Results Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Tips for Taking your Medicine Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Using a Metered Dose Inhaler with a Spacer Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Using a Diskus Inhaler Module 1 – Asthma & Asthma Medications PDF | MS Word PDF | MS Word Goals for Getting Rid of Dust Mites Module 2 – Safe Sleeping Zone PDF | MS Word PDF | MS Word Goals for Getting Rid of Cockroaches Module 3 – Cockroach PDF | MS Word PDF | MS Word Goals for Getting Rid of Mice and Rats Module 4 – Rodent PDF | MS Word PDF | MS Word Goals for Cutting Down on your Contact with Pets Module 5 – Furry Friends PDF | MS Word PDF | MS Word Goals for Getting Rid of Mold Module 6 – Mold PDF | MS Word PDF | MS Word Goals for Avoiding Exposure to Smoke Module 7 – Environmental Tobacco Smoke PDF | MS Word PDF | MS Word Goals for Controlling Other Things that Make Asthma Act Up Module 8 – Other Asthma Triggers PDF | MS Word PDF | MS Wo
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