Supplemental File 1:Department of Child Health,
Newcastle upon Tyne, Respiratory Questionnaire.
Contact InformationStudy Number______Date______
Child’s name______
surname other names
Address______
______
postcode
School______Class Teacher______
Mother’s name______
surnameother names
Father’s name______
surnameother names
Telephone______
numberhomework
Personal Information
1. What is your child’s date of birth?____/______/______
daymonthyear
2. Is your child male or female?m ______f______
3. Where was he / she born?______
hospitaltown
4. Was he / she born more than 2 weeksNo_____ (go to question 6)Yes____(go to question 5)
before his / her due date?
5. How early was he / she?______
weeksdays
______
ORgestational age
6. What was your child’s birth weight?______
poundsounces
______
ORkilograms
7. Was your child exclusively breast fed No_____ (go to question 9)Yes____(go to question 8)
before weaning?
(by ‘exclusively’, we mean only breast milk)
8. For how long did you breast feed______
before weaning?weeksmonths
9. Did your child attend a nursery school?No____(go to question 12) Yes___ (go to question 10)
(by nursey we mean any form of daycare eg playgroup)
10. What was your child’s attendance?Full Time______Part Time______
11. At what age did your child start nursery?______
yearsmonths
12. What are the parents’ dates of birth?______/ ______/______/ _____/ ____
(by father we mean a significant other in daymonthyearday month year
in the household)father mother
13. What are the parents’ occupations?______
(by father we mean a ‘significant other’father / guardianmother / guardian
in the household)
14. At what age did the parents complete______
full time education, for example father / guardianmother / guardian
school, college, university?
(by father we mean a ‘significant other’
in the household)
Wheeze and Asthma
15. Has your child ever wheezed?No______Yes______
(by wheeze we mean a noise from the chest that sounds like….)
If yes, was this in the last 12 months?No______Yes______
In the last 12 months, how many times did your child wheeze?not at all ______
< 4 times______
4-12 times______
>12 times______
How old was your child when the wheezing first began?______years old
16. Has your child ever had wheezing during or after exercise?No______Yes______
If yes, was this in the last 12 months?No______Yes______
17. Has your child ever been diagnosed as having asthmaNo ______Yes______
by a doctor or at a hospital?
If yes, how old was your child when the asthma was first ______
diagnosed?years old
Has you child got a current diagnosis of asthma?No______Yes______
How often does your child see a doctor about asthma?not at all______
once a year______
every 6 months__
> 6 months _____
18. Has your child ever take any medicine for asthma?No______Yes______
(medicine includes inhalers, liquids, tablets, nebulisers)
In the last 12 months, how often has your childnot at all______
Taken medicine for asthma?
< once a month__
> once a month__
every day______
In the last 12 months has he /she taken any eithersalbutamol(ventolin)
of the following medicines for asthma?or terbutaline (bricanyl)
No___Yes ____DK_____
sodium cromoglycate (intal) :
No___Yes ____DK_____
either beclamethasone (becotide)
orbudesonide (pulmicort)
orfluticasone (flixotide):
No___Yes____DK_____
other:
please specify ______
Has your child EVER taken salbutamol (ventolin)No____Yes_____ DK___
or terbutaline (bricanyl)?
If yes, at what age did your child first take this medicine?______years old
19. Has your child ever had to spend a night in hospitalNo______Yes______
because of breathing problems?
If yes, was this in the last 12 months?No______Yes______
20. In the last 12 months, has your child visited a hospitalNo______Yes______
casualty department or been seen urgently by a
doctor because of breathing problems?
21. In the last 12 months has asthma or wheezingNo______Yes______
limited your child’s activities?
22. In the last 12 months has your child’s sleepNo ______Yes______
been disturbed by asthma or wheezing?
23. In the last 12 months has your child missed schoolNo ______Yes______
because of asthma or wheezing?
Cough not associated with a cold or flu
24. In the last 12 months has your child ever had No__(go to question 28)Yes__(go to question 25)
a cough which lasted more than 3 weeks
and was not associated with a cold or flu?
25. In the last 12 months, how many times has your< 4 times______
child had a cough which lasted more than 3
weeks and was not associated with a cold or flu?4-12times ______
>12 times______
What time of day has the cough been worse? Day______Night______
What season has the cough been worse?Summer ______
Autumn ______
Winter ______
Spring ______
26. In the last 12 months has your child seen a doctorNo______Yes______
because of a cough which lasted more than 3 weeks
and was not associated with a cold or flu?
27. In the last 12 months has your child taken any medicineNo______Yes______
for cough which was not associated with a cold or flu?
If yes, what medicine?______
Other Illnesses
28. Has your child ever been admitted to a hospital with a No______Yes_____
pneumonia or chest infection?
29. Was your child treated by a doctor or at a hospital for No______Yes_____
a serious respiratory illness such as bronchitis,
bronchiolitis or pneumonia before the age of 2?
If yes, which respiratory illness?Bronchitis______
Bronchiolitis______Pneumonia ______
30. In the last 12 months has your child had attacks ofNo______Yes _____
hayfever or nasal allergies?( sneezing, running or
blocked nose, sometimes with itchy eyes, not associated with a cold)
31. In the last 12 months has your child had eczema?No ______Yes _____
Family History
32. Has the child’s natural father ever hadasthmaNo___ Yes ___ DK ____
hayfever/No___ Yes____ DK ____
nasal allergies
eczemaNo ___Yes ____DK ____
33. Has the child’s natural mother ever hadasthmaNo___ Yes ____ DK ___
hayfever/No___ Yes ____ DK ___
nasal allergies
eczemaNo ___ Yes ____ DK ___
Home Environment
34. How many people live in your household?______
number of people
35. Did the child’s mother smoke during pregnancyNo______Yes _____
or the first 2 years of the child’s life?
If yes, approximately how many cigarettes were______
smoked per day?number of cigarettes
36. Did the child’s father smoke during the first 2 No______Yes______
years of the child’s life?
If yes, approximately how many cigarettes were______
smoked per day?number of cigarettes
36. Approximately how many cigarettes are smoked ______
in the house daily now?number of cigarettes
End of Questionnaire.
Investigator to tick one of the following categories that best describes child:
1. No persistent cough and / or frequent wheeze______
Dr diagnosis of CRD______
No Dr diagnosis of CRD______
2. Frequent wheeze______
3. Persistent cough and frequent wheeze______
4. Persistent cough______
30/10/2018 v1.1