1
Modified ISAAC Fase 3 America Latina
Translated from ISAAC Questionnaires (ISAAC Manual, Core questionnaires for wheezing and asthma
(including video-questionnaire); rhinitis, and eczema. Children aged 6-7 and 13-14 years). Adapted for local
Chilean colloquial language. Headings (asthma, rhinitis, eczema questionnaires, have been omitted
according to ISAAC recommendations). Back-translation performed on March 2004. Prof. Javier Mallol,
Regional Coordinator.
QUESTIONNAIRE: ALLERGY AND RESPIRATORY SYMPTOMS. CHILDREN 6-7-YEAR-OLD
(TO BE ANSWERED BY PARENT OR PROXY)
Instructions for answering the questions
On this sheet there are questions about your child’s name, school, and birth date. Please write your answers to
these questions in the space provided.
All other questions require you to tick your answer in a box or dotted line next to the option you choose (YES
or NO). Tick only one option unless otherwise instructed. This information is strictly confidential.
Examples of how to answer the questionnaire:
Age ...7.... year-old
To answer YES:
YES ...X..
NO .....
To answer NO:
YES .....
NO ...X..
School: ________________________________________________________
Today’s Date:
_____
Day
________
Month
__________
Year
Child’s Name: _________________________________________________
Child’s Age: .........years
Gender:
Child’s date of birth:
Male .......... Female ..............
____ _______
Day
Month
________
Year
2
Modified ISAAC Fase 3 America Latina
Questionnaire for 6 and 7 year olds
1.
Has your child ever had wheezing or whistling in the chest at any time in the past?
YES..............
NO.............
IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION 6
2. Has your child had wheezing or whistling in the chest in the last 12 months?
YES.............
NO...........
3. How many attacks of wheezing has your child had in the last 12 months?
NONE............
1 to 3.............
4 to 12..............
More than 12...........
4. In the last 12 months, how often, on average, has your child’s sleep been disturbed due to wheezing?
Never
Less than one night per week
One or more nights per week
.................
.................
.................
5. In the last 12 months, has wheezing ever been severe enough to limit your child’s speech to only one or two
words at a time between breaths?
YES.............
NO...........
6. Has your child ever had asthma?
YES ...............
NO .............
7. In the last 12 months, has your child’s chest sounded wheezy during or after exercise (running, playing,
practicing sports, etc.)?
YES.............
NO..............
8. In the last 12 months, has your child had a dry cough at night, apart from a cough associated with a cold or
chest infection?
YES.............
NO..............
3
Modified ISAAC Fase 3 America Latina
ALL QUESTIONS IN THE NEXT SECTION ARE ABOUT NASAL PROBLEMS WHEN YOUR CHILD
DOES NOT HAVE A COLD OR THE FLU.
1. Has your child ever had a problem with sneezing, or a runny or blocked nose when he/she DID NOT have a
cold or the flu?
YES...............
NO................
IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION 6
2. In the past 12 months, has your child had a problem with sneezing, or a runny, or blocked nose when he/she
DID NOT have a cold or the flu?
YES...............
NO...............
3. In the past 12 months, has this nose problem been accompanied by itchy-watery eyes?
YES ...............
NO ..............
4. In which of the past 12 months did this nose problem occur? (Please tick any which apply)
January................
February.............
March.............
May................
June
July .............
September............
October .............
.............
April.............
August.........
November.......... December..............
5. In the past 12 months, how much did this nose problem interfere with your chid’s daily activities?
Not at all.............. A little.............
A moderate amount............... A lot..............
6. Has your child ever had hayfever?
YES..............
NO.............
Modified ISAAC Fase 3 America Latina
1. Has your child ever had an itchy rash that was coming and going for at least six months?
YES.............
NO............
IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION 7
2. Has your child had this itchy rash at any time in the last 12 months?
YES...............
NO.............
3. Has this itchy rash at any time affected any of the following places? (the folds of the elbows, behind the
knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?)
YES.................
NO................
4. Has this rash cleared completely at any time during the last 12 months?
YES..............
NO..............
5. Age this skin problem (itchy rash) appeared for the first time:
<2 years.......
2-4 years.......
5 or more years......
6. In the last 12 months, how often, on average, has your child been kept awake at night by this itchy rash?
Never in the last 12 months..............
Less than one night per week..............
One or more nights per week.............
7. Has your child ever had eczema?
YES..............
NO.............
4
Protocol #
ASTHMA QUESTIONNAIRE
__________________
Date:
__/__/____
Name and surname:
________________________________
Birth date:
__/__/____
Age:
_ _ years
V 1. 0
MODIFIED BONNER
(dd/mm/yyyy)
(dd/mm/yyyy)
_ _ months
1. Has your child ever had wheezing/whistling in the chest?
(1) Yes
(2) No
2. Has your child ever had cough for more than a week, with or without a cold?
(1) Yes
(2) No
3. Has your child ever had any other respiratory condition?
(1) Yes
(2) No
4. In the last 12 months, has your child had any of the following: chest wheezing or whistling, cough for more
than a week or other respiratory condition?
(1) Yes
(2) No
5. In the last 12 months, how many times has your child had any of the following: chest wheezing or
whistling, cough for more than a week or other respiratory condition?
( ) Number of times
(0 if none)
6. In the last 12 months, how many nights has your child had disturbed sleep due to wheezing/whistling,
cough or other respiratory problem?
( ) Number of times
(0 if none)
7. I will read out to you the names of certain conditions. Please tell for each one of them if any doctor ever
used it to describe a problem in your child.
Asthma
(1) Yes (2) No
Bronchial hyperreactivity (1) Yes (2) No
Bronchitis or bronchiolitis (1) Yes (2) No
Wheezing or whistling
(1) Yes (2) No
8. In the last 12 months, has a doctor prescribed your child respiratory medicines, inhaled, nebulized or in any
other form, or a respiratory device to treat any of the previous conditions?
(1) Yes
(2) No
9. In the last 12 months, has your child received any medicine for wheezing of the chest or other respiratory
problem?
(1) Yes
(2) No
10. In the last 12 months, has your child received any medicine for cough during more than a week, with or
without a cold?
(1) Yes
(2) No
11. In the last 12 months, how many times did your child visit the pediatrician or the Emergency Ward for
asthma, chest wheezing, cough, chest pain or difficult breathing?
Protocol #
ASTHMA QUESTIONNAIRE
__________________
V 1. 0
( ) Number of times
MODIFIED BONNER
(0 if none)
12. In the last 12 months, how many times your child had to remain overnight in the Emergency Ward due to
asthma, chest wheezing, cough, chest pain or difficult breathing?
( ) Number of times
(0 if none)
13. In the last 12 months, how many MONTHS did your child assist to school or kindergarten?
( ) Number of times
(0 if none)
14. In the last 12 months, how many DAYS did your child skip school or kindergarten due to asthma, chest
wheezing, cough, chest pain or difficult breathing?
( ) Number of times
(0 if none)
15. Is your child currently under medical treatment due to asthma, chest wheezing, cough, chest pain or
difficult breathing?
(1) Yes
(2) No
16. Has your child had chest wheezing or whistling at least three times in his/her life?
(1) Yes
(2) No