| Questionnaire | |||
| Case Number________________ | |||
| Date___/___/___ | |||
| Diagnosis___________________ | |||
| Date of Birth___/___/___ | Date of hospitalization and discharge___/___/___ | ||
| Gestational Age | ___ week | Birth weight _______ g | |
| Breast-feeding | __ yes | ___no | # months ______ (exclusive: #months ____) |
| School Attendance by siblings | |||
| Brothers/Sister | __ yes | ___no | #___ |
| Familiarity for asthma | __ yes(*) | ___no | |
| Mother | __ yes | ___no | |
| Father | __ yes | ___no | |
| Brothers/Sister | __ yes | ___no | #___ |
| Familiarity for rhino-conjunctivitis | __ yes(*) | ___no | |
| Mother | __ yes | ___no | |
| Father | __ yes | ___no | |
| Brothers/Sister | __ yes | ___no | #___ |
| Familiarity for eczema | __ yes(*) | ___no | |
| Mother | __ yes | ___no | |
| Father | __ yes | ___no | |
| Brothers/Sister | __ yes | ___no | #___ |
| Smoking habit | |||
| Mother | __ yes | ___no | cig per day ____ |
| Mother during | |||
| pregnancy | __ yes | ___no | cig per day ____ |
| Father | __ yes | ___no | cig per day ____ |
| Other house living | __ yes | ___no | cig per day ____ |
| ________________________________________________________ | |||
(*)Yes at least one parent