1. How do you come to know about this clinic – swasa.

Through Doctor

Newspaper

Patient

Friends

Boards

TV Channels

others if any please write down:_________________________

2. What are your [Patient] problems?

Cough & Cold

Difficulty in breathing

Chest tightness

Sneezing & running nose

Itching of eyes – Nose – Throat – ears – skin

Others if any please write down:_________________________

3. What get disturbed by your problem?

Sleep disturbance

Disturbance at work

Studies

Games

Growth

Mental Peace

Family life

Social respect

Family (Economics)

other if any please write down:___________________________

4. Which triggers your problem?

Dust

Weather changes

Some foods

Cool drinks, Ice-cream, Chacolates & sweets

Chemical & Drugs, Scents

Smoke

Physical Exercise or games

Emotional feelings like laughing or crying, Mental stress, etc.

others if any please write down:_____________________________

5. Associated problems or habits?

Smoking

Alcohol

Gutka or pan masala

Diabetes (sugar)

Hypertension (B.P)

Heart problem

TB

Dental problem

Arthritis

others if any please write down:_______________________________

6. Who else is suffering with similar problems in your family or Relations.?

Father

Mother

Son

Daughter

Grand Parents

Uncles or Aunties

Cousins

other blood relation if any_____________________________

7. What treatment so far you have taken for your problem?

Allopathy (English Medicines)

Homeopathy

Ayurvedic

Unani

Fish Medicine

Lodge Medicines

Antibiotics & Cough Syrup

Asthalin inhaler or Rota Cap

Directly from Medical shop

RMP Treatment

Friends or others patients

others if any please write down:_______________________________

8. How many doctors you have visited so far.

1

2

3

4 or more

others if any please write down:_____________________________

9. Operations or tests done for your problem?

Nose operation

Ear operation

Throat operation (for Adenoids or tonsils)

Angiogram

Bypass Surgery

Sinus cleaning or surgery

C.T.Scan

Blood tests

Spirometry - PFT

sputum test:

Mention if any other test or operation

others if any please write down:______________________________

10. Your problem is treated as:

Simple cough & cold

As throat infection

As viral fever or typhoid fever

As nose or sinus problem

As Heart problem

As TB

As general Weakness

As psychological problem

Others if any please write down:______________________________

11. You are worried about what?

About future life

About growth & studies

About carrier

About marriage

About side effects of drugs

About cost of treatment

About quality of treatment

Or mention if any:_________________________________________

12. what type of awareness programmes are required to educate about Asthma.

T.V.Programs

News paper

Books

Boards or Hoardings

Asthma camps

Asthma education programs at schools, colleges, offices & at work place:

others if any please write down:_________________________________

13. How often you are suffering with this problem:

Since Birth or childhood

Occasionally

Frequently

Regularly – daily

Others if any please write down:__________________________________

14. How do you feel about the problem:

Get vexed / Frustrated

Get disturbed

Get depressed

Lost Hope of life & future

Others if any please write down:_____________________________

15. What are your expectations after treatment:

Freedom from suffering

Freedom to breathe..

Freedom to work, study or play or move socially

This problem should not repeat again & again

Others if any please write down:________________________________