Asthma Questionnaire ACT

This is a validated sleep questionnaire for children twelve years and under.

Answer as best you can for what you have noticed in the last four weeks.

Child's name (optional)

First NameLast Name

In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
(1)

During the past 4 weeks, how often have you had shortness of breath?

	More than once a day	Once a day	3-6 times a week	Once or twice a week	Not at all
(2)

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

	4 or more nights a week	2-3 nights a week	Once a week	Once or twice	Not at all
(3)

During the past 4 weeks, how often have you used your reliever medication (such as salbutamol)?

	3 or more times per day	1-2 times per day	2-3 times per week	Once a week or less	Not at all
(4)

How would you rate your asthma control during the past 4 weeks?

	Not controlled at all	Poorly controlled	Somewhat controlled	Well controlled	Completely controlled
(5)

ACT Score

Your score (19 or less) suggests asthma may not be controlled as well as it could be. Talk to your health professional.

Your score (20 or more) suggests the asthma is fairly well controlled. If you are still concerned talk to your health professional.

Reference: 1. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.

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