Asthma Symptoms
Checklist

Is it hard to breathe after exercise? Do you hear wheezing? Do you have frequent respiratory infections? Find out if it may be asthma. Complete this checklist based on guidelines by the National Heart, Lung, and Blood Institute, a part of the National Institutes of Health. Then review your symptoms with your doctor. Only your healthcare provider can diagnose asthma.

Place a check mark in the box next to any symptom that you have had:

A whistling or wheezing sound when you breathe
Coughing
Shortness of breath
Tightness in your chest
None of the above

Do any of these asthma triggers make your symptoms worse?

Exercise
Infection (colds or the flu)
Animals with fur or hair
Dust mites (in mattresses, pillows, upholstered furniture, carpets)
Mold
Smoke (tobacco, wood)
Pollen
Airborne chemicals or dust
Changes in weather
Laughing or crying hard
Stress
Cold air
Heat/humidity
None of the above

Do your symptoms get worse at night or wake you up?

Yes
No

Click the “Print” button below to print this page. Use this checklist to talk with your healthcare provider about your symptoms.

Asthma Assessment

Your Symptoms and Control Checklist

Your Results

Asthma Assessment

Your Symptoms and Control Checklist

Use this checklist to review your symptoms with your healthcare provider.

Symptom(s) you have had:

These things trigger or make your symptom(s) worse:

Do your symptoms get worse at night or wake you up?

Approved Uses
QVAR® (beclomethasone dipropionate HFA) Inhalation Aerosol is used in the ongoing treatment of asthma as preventative therapy in patients 5 years of age or older.

Important Safety Information
  • QVAR does not replace quick-relief inhalers for sudden symptoms
  • Do not use QVAR if you are allergic to beclomethasone dipropionate or any of the ingredients in QVAR
  • Do not use QVAR more often than it is prescribed. Do not stop taking QVAR abruptly without talking to your healthcare provider
  • QVAR may cause serious side effects, including:
    • Fungal infections (thrush). Tell your healthcare provider if you have any redness or white-colored patches in your mouth or throat. Rinse your mouth with water without swallowing after using QVAR to help prevent an infection in your mouth or throat
    • Worsening asthma or sudden asthma attacks. After using your rescue inhaler, contact your healthcare provider right away if you do not get relief from your sudden asthma attacks
    • Reduced adrenal function. This potentially life-threatening condition can happen when you stop taking oral corticosteroid medicines and start using QVAR. Tell your healthcare provider right away about any symptoms such as: tiredness, weakness, nausea and vomiting, and dizziness or faintness
    • Immune system effects or infection. Tell your healthcare provider about any signs or symptoms, such as: fever, pain, body aches, chills, feeling tired, nausea, or vomiting
    • Increased wheezing right after QVAR use. Always have a rescue inhaler with you to treat sudden wheezing
    • Serious allergic reactions. Stop using QVAR and call your healthcare provider or get emergency medical help right away if you get any of the following: hives; swelling of your lips, tongue, or face; rash; or breathing problems
    • Slowed growth in children. Children should have their growth checked regularly while using QVAR
    • Lower bone density. This may be a problem for people who already have a higher chance for this condition
    • Eye problems. If you have had glaucoma, cataracts or blurred vision in the past, you should have regular eye exams while using QVAR
  • The most common side effects of QVAR include: headache, throat irritation, and sinus irritation

  • Please see full Prescribing Information

    You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.