Asthma Control Test

1

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

[1] All Of The Time

[2] Most Of The Time

[3] Some Of The Time

[4] A Little Of The Time

[5] None Of The Time

2

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

[1] More Than Once A Day

[2] Once A Day

[3] 3 to 6 Times A Week

[4] One Or Twice A Week

[5] Not At All

3

In 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?

[1] 4 Or More Nights A Week

[2] 2 to 3 Nights A Week

[3] Once A Week

[4] Once Or Twice

[5] Not At All

4

In the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as Albuterol, Ventolin, Proventil, Maxair, Primatene Mist)?

[1] 3 Or More Times Per Day

[2] 1 to 2 Times Per Day

[3] 2 or 3 Times Per Week

[4] Once A Week Or Less

[5] Not At All

5

How Would You Rate Your Asthma Control During The Past 4 Weeks?

[1] Not Controlled At All

[2] Poorly Controlled

[3] Somewhat Controlled

[4] Well Controlled

[5] Completely Controlled

6

1. For information on the interpretation and scoring of the Asthma Control Test (ACT) visit, www.asthmacontroltest.com.

2. The ACT is a validated instrument for assessment of asthma control. The scores range from 5 (poor control of asthma) to 25 (complete control of asthma), with a higher score reflecting greater asthma control. An ACT score of >19 indicates well-controlled asthma.