Asthma Control Test

1

Patient's Name

First Name

Last Name

2

Patient Date of Birth

Date

3

Is your child between the ages of 4 and 11 years

YESNO

4

How is your asthma today?* This field is required.Question 1

Very Bad

Bad

Good

Very Good

5

How much of a problem is your asthma when you run, exercise or play sports?* This field is required.Question 2

It's a big problem, I can't do what I want to do.

It's a problem and I don't like it.

It's a bit of a problem but it's okay.

It's not a problem.

6

Does your asthma make you cough?* This field is required.Question 3

Yes, all the time.

Yes, most of the time.

Yes, sometimes.

No, never

7

Does your asthma make you wake up during the night?* This field is required.Question 4

Yes, all the time.

Yes, most of the time.

Yes, sometimes.

No, never

8

During the last 4 weeks, how many days did your child have any daytime asthma symptoms?* This field is required.Question 5

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day

9

During the last 4 weeks, how many days did your child wheeze during the day because of asthma?* This field is required.Question 6

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day

10

During the last 4 weeks, how many days did your child wake up during the night because of asthma?* This field is required.Question 7

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day

11

During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home?* This field is required.Question 1A

All of the time

Most of the time

Some of the time

A little of the time

None of the time

12

During the last 4 weeks, how often have you had shortness of breath?* This field is required.Question 2A

More than once a day

Once a day

3 to 6 times a week

Once or twice a week

None at all

13

During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning?* This field is required.Question 3A

4 or more nights a week

2 to 3 nights a week

Once a week

Once or Twice

Not at all

14

During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)?* This field is required.Question 4A

3 or more times per day

Once or twice per day

2 or 3 times per week

Once a week or less

Not at all

15

How would you rate your asthma control during the last 4 weeks?* This field is required.Question 5A

Not Controlled at all

Poorly Controlled

Somewhat Controlled

Well Controlled

Completely Controlled

16

ACT Score