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This work is licensed under a Creative Commons Attribution 3.0 Unported License.

2012 Barbara Massoudi

BreathEasy ODL Questionnaire

All questions are in bold, and backend logic is in blue within parenthesis.

1. What date are you entering data for?[Textbox for answer. Default to todays date. No future dates. Allow participant to

enter previous days data.]

2. Please enter your peak flow rate for today.[Input mask to a 3 digit number. A missing value is acceptable.]

3. Did you take your controller medications as directed today?Yes

No

[If Yes, go to 5, if No, go to 4.]

4. Please tell us why you didn't take the controller medications as directed today?[Textbox for answer]

5. Did you use any rescue medications today?Yes

No

[If Yes, go to 6, if No, go to 7.]

6. Why did you take your rescue medication? (select all that apply)Wheezing

Coughing

Shortness of breath

Tightness in chest

For prevention of symptoms

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Other

[If other is selected, then move to question 6a.]

a. What was the other reason for taking your rescue medication?[Textbox for answer]

7. Did you come across any asthma triggers today?Yes

No

[If Yes, go to 8, if No, go to 9.]

8. Which trigger(s) did you come across today? (select all that apply)Animal dander

Dust mites

Cockroaches

Indoor mold

Pollen and outdoor mold

Tobacco smoke

Other smoke, strong odors and sprays

Other

[If other is selected, then move to question 8a.]

a. Which other trigger did you come across today?[Textbox for answer]

9. Did you have asthma symptoms today?Yes

No

[If Yes, go to 10, if No, go to 11]

10.What asthma symptoms did you have today? (select all that apply)

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Chest tightness

Wheezing

Coughing

Shortness of Breath

Other

[If other is selected, then move to question 10a.]

a. What other asthma symptoms did you have today?[Textbox for answer]

11.How active would you say you were today? (select one)Not Active

Somewhat Active

Very Active

[IfNot Active, go to 15, else, go to 12]

12.Please select your activities today? (select all that apply)Walking

Running

Swimming

Aerobics

Basketball

Other

[If other is selected, then move to question 12a.]

a. In what other ways were you active today?[Textbox for answer]

13.How long were you active today?

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Less than 30 minutes

30-60 minutes

60-90 minutes

90 - 120 minutes

More than 120 minutes

14.Please enter number of steps on your accelerometer.[ An open numeric field. A missing value is allowed.]

15.Use the scale to show how you are feeling today (select one)Happy [with icon]

Okay [with icon]

Down [with icon]

Depressed [with icon]

16.Use the scale to show how you are feeling today (select one)Happy [with icon]

Okay [with icon]

Anxious[with icon]

Worried[with icon]

17.How did you sleep the past 24 hours? (select all that apply)Difficulty falling asleep

Difficulty staying asleep

Sleeping too little

Sleeping the right amount

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Sleeping too much

18.Did your asthma limit your daily activities today in any way?Yes

No

19.Did you smoke today?Yes

No

[If Yes, go to 20, if No, end of survey.]

20.How many cigarettes/cigars/pipes did you smoke today?[Textbox for answer, then move on to Save and send data]