Name __________________________ ______________

Year & Section _________ Contact No. _____________

Name __________________________ ______________

Year & Section _________ Contact No. _____________

SURVEY
SURVEY
1.
2.

Are you asthmatic? __ Yes __ No

What triggers your asthma?

1.

___________________________________________
3.

What type of medication are you taking?

__ Inhaler
__ Table
__ Viscous
__ Others, ________________________

2.

Are you asthmatic?

__ Yes
What triggers your asthma?

__ No

___________________________________________
3.

What type of medication are you taking?

__ Inhaler
__ Table
__ Viscous
__ Others, ________________________

Please specify brand name ______________________

Please specify brand name ______________________
4.

How long have you been taking such medication?

___________________________________________
When did you last take this medication?
___________________________________________
Since you take this medication have you notice that
you are more susceptible to caries? ____ Yes ____ No

5.
6.

Name __________________________ ______________

Year & Section _________ Contact No. _____________

4.

How long have you been taking such medication?

___________________________________________
When did you last take this medication?
___________________________________________
Since you take this medication have you notice that
you are more susceptible to caries? ____ Yes ____ No

5.
6.

Name __________________________ ______________

Year & Section _________ Contact No. _____________

SURVEY
1.
2.

Are you asthmatic?

__ Yes
What triggers your asthma?

SURVEY
__ No

1.
2.

___________________________________________
3.

What type of medication are you taking?

__ Inhaler
__ Table
__ Viscous
__ Others, ________________________

5.
6.

How long have you been taking such medication?

___________________________________________
When did you last take this medication?
___________________________________________
Since you take this medication have you notice that
you are more susceptible to caries? ____ Yes ____ No

__ No

___________________________________________
3.

Please specify brand name ______________________

4.

Are you asthmatic?

__ Yes
What triggers your asthma?

What type of medication are you taking?

__ Inhaler
__ Table
__ Viscous
__ Others, ________________________
Please specify brand name ______________________

4.
5.
6.

How long have you been taking such medication?

___________________________________________
When did you last take this medication?
___________________________________________
Since you take this medication have you notice that
you are more susceptible to caries? ____ Yes ____ No