You can always press Enter⏎ to continue
Are you breathing safe?
START
1
During the past week, how many days have you had asthma symptoms? Cough, chest tightness, shortness of breath, spit, mucus, phlegm when coughing?
*
This field is required.
0 days
1-2 days
3-6 days
Every day not all day long
Every day all day long
Previous
Next
Submit
Press
Enter
2
During the past week, how many days have you had to take medicine to quickly relieve asthma symptoms? Albuterol, Proventil, ProAir, Ventolin or Xopenex by inhaler, spray, pump, machine or nebulizer?
*
This field is required.
0 days
1-2 days
3-6 days
Every day not all day long
Every day all day long
Previous
Next
Submit
Press
Enter
3
During the past week, how many days did you have an asthma attack? When it is harder for you to breath; when you take more quick-relief asthma medicine (Albuterol), or when asthma medicine does not work.
*
This field is required.
0 days
1 day
2-3 days
4 - 7 days
Previous
Next
Submit
Press
Enter
4
During the past week, how much has asthma limited your activities?
*
This field is required.
Not at all
Slightly
Moderately
Very much
Completely
Previous
Next
Submit
Press
Enter
5
During the past TWO WEEKS, how many NIGHTS did asthma keep you from sleeping or wake you up?
*
This field is required.
0 days
1 night
2 nights
3-7 nights
8-14 nights
Previous
Next
Submit
Press
Enter
6
Calculation
*
This field is required.
Previous
Next
Submit
Press
Enter
7
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
7
See All
Go Back
Submit
