Asthma: Asthma Control Test (ACT)
Patient Name
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First Name
Last Name
Patient Date of Birth
*
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Month
-
Day
Year
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?
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All of the time
Most of the time
Some of the time
A little of the time
None of the time
2. During the past 4 weeks, how often have you had shortness of breath?
*
More than once a day
Once a day
3 to 6 times a week
Once or twice a week
Not 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 week
2 or 3 nights a week
Once a week
Once or twice
Not at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
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3 or more times per day
1 or 2 times per day
2 or 3 times per week
Once a week or less
Not at all
5. How would you rate your asthma control during the past 4 weeks?
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Not controlled at all
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
Submit
Score
Should be Empty: