Asthma Control Test (12+ Years)

Asthma Control Test

For patients 12 years and older
This is a quick test that provides a numerical score to assess asthma control. Please answer each question, note your total score, and discuss your results with your doctor.
Patient 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?
2. During the past 4 weeks, how often have you had shortness of breath?
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. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
5. How would you rate your asthma control during the past 4 weeks?
Score
If your score is 19 or less, your asthma may not be under control. Be sure to talk with your doctor about your results.
In the past 12 months, how many emergency department visits have you had due to asthma(that did not result in a hospitalization)?
This answer should be discussed with your doctor.
In the past 12 months, how many inpatient hospitalizations have you had due to asthma?
This answer should be discussed with your doctor.
Should be Empty: