Tuffies Lung Health Screening Form
1. Name of your child:
2. Full Name of School:
3. City :
4. Roll number :
5. Age of the child:
6. Standard (Std):
7. Division:
8. Symptoms lasting more than 24 hours: (Select at least one)
Cough
Breathlessness
Wheeze
Chest Tightness
None of the above
0
9. Frequency of symptoms:
Less than 2 times/year
More than 2 times/year
0
10. Coughing while playing or sleep disturbance:
Yes
No
0
11. How are symptoms relieved? (Select at least one)
Oral Medications
Nebulization
Inhalers
0
12. Hospitalization due to symptoms:
Yes
No
0
13. Triggers or aggravators: (Select at least one)
Change in weather
Exposure to dust
Cold foods
Physical activity
None of the above
0
14. Allergies (skin/nose):
Yes
No
0
15. Family history of asthma/allergy:
Yes
No
0
Parent/Guardian Full Name (Witness):
I, as the Parent/Guardian, confirm that I have read and agree to the terms and conditions for this lung health screening.
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Total Score:
0
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Please complete all required fields and select at least one option for the highlighted questions.
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