Respiratory Inhaler Assessment Form
Complete this Respiratory Inhaler Assessment Form to evaluate your inhaler use and respiratory symptom control.
Which type of inhaler do you primarily use?
*
Metered-dose inhaler (MDI)
Dry powder inhaler (DPI)
Soft mist inhaler (SMI)
Nebulizer
Other
How often do you use your inhaler?
*
Daily
Several times a week
Once a week or less
Only as needed
How confident are you in your inhaler technique?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Have you received training on how to use your inhaler?
*
Yes, from a healthcare professional
Yes, from online resources
No, self-taught
No training received
How often do you experience respiratory symptoms (e.g., wheezing, coughing, shortness of breath)?
*
Several times a day
Once a day
A few times a week
Rarely
Never
How would you rate the severity of your respiratory symptoms over the past week?
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
In the past week, how much have your symptoms interfered with your daily activities?
*
Not at all
1
2
3
4
Extremely
5
1 is Not at all, 5 is Extremely
Please indicate your level of agreement with the following statements:
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I use my inhaler as prescribed
1
2
3
4
5
I remember to take my inhaler on time
6
7
8
9
10
I find it easy to use my inhaler
11
12
13
14
15
I understand the instructions for my inhaler
16
17
18
19
20
How satisfied are you with your current inhaler device?
*
1
2
3
4
5
Do you have any difficulties or concerns related to your inhaler use?
*
No difficulties or concerns
Difficulty coordinating inhalation
Device is hard to use
Unpleasant taste or side effects
Unsure about correct technique
Other
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