Asthma Control Test 12 years and older

Asthma Control Test™

12 years and older
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
1. 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 timeMost of the timeSome of the timeA little of the timeNone of the time
2. During the past 4 weeks, how often have you had shortness of breath?

More than once a dayOnce a day3 to 6 times a weekOnce or twice a weekNot at all
3.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 week2 or 3 nights a weekOnce a weekOnce or twice a weekNot at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

3 or more times per day1 or 2 times per day2 or 3 times per weekOnce a week or lessNot at all
5. How would you rate your asthma control during the past 4 weeks? 1 at all controlled controlled

Not controlled at allPoorly controlledSomewhat controlledWell controlledCompletely controlled
In the past 12 months, how many emergency department visits have you had due to asthma
in the past 12 months, how many inpatient hospitalizations have you had due to asthma?
Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. The Asthma Control Test is for people with asthma 12 years and older. References: 1. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007 NIH Item 08-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm Accessed September 10, 2007. 2. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.
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Asthma Control Test™

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