Smoking Questionnaire for Children and Teenagers with Asthma

This form needs to be completed by the parents/guardians of children and young people.Teenagers can complete this directly themselves if they wish.

Please complete the Asthma Review here, if you have not had a review last year.

Are You: *  
Is this review for:  

Personal Details

Do you smoke? *  
Are there any other smokers within your household? *  
Fields marked with an asterisk (*) are mandatory