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Month __________ Day
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Last night
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Good night
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Slept well but some wheeze or cough
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Awake briefly with wheeze or cough
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Bad night, awake repeatedly
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Morning Peak Flow
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(best of 3 efforts)
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Activity
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Vigorous activity OK
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Can run only briefly
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OK for walking only
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Must rest at home
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Wheeze
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None
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Briefly, not troublesome
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Several times
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Continuous
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Cough
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None
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Present but not troublesome
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Interrupted activities once
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Interrupted activities more than once
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Evening Peak Flow
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(best of 3 efforts)
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Intervention
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Inhaled bronchodilators (no. of treatments)
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Oral Corticosteroid (dose)
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