Asthma Control Test 12 and up

Asthma Control Test™ Is:
- A quick test that provides a numerical score to assess asthma control.
- Recognized by the National Institutes of Health (NIH) in its 2007 asthma guidelines.¹
- Clinically validated against spirometry and specialist assessment.²
For Patients 12 Years and Older:
1. Answer each question and write the answer number in the box to the right of each question.
2. Add your answers and write your total score in the TOTAL box shown below.
3. Discuss your results with your doctor.
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? (1= all the time. 2= most of the time. 3= some of the time. 4=a little of the time. 5= none of the time)

1

2

3

4

5

1 is All of the time , 5 is 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= 3-6 times a week. 4=once or twice a week. 5= not at all)

1

2

3

4

5

1 is More than once a day, 5 is 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? (1= 4 or more nights a week. 2= 2-3 nights/wk. 3= once a week. 4= once or twice. 5=not at all.

1

2

3

4

5

1 is 4 or more nights a week, 5 is not at all
4. During the past 4 weeks, how often have you used your rescue inhaler (albuterol)? Or you would have used it if you had it available? (1 = 3 or more times per day. 2= 1-2times/day. 3= 2-3 times/week. 4=once a week or less. 5=not at all

1

2

3

4

5

1 is 3 or more times per day, 5 is 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.)

1

2

3

4

5

1 is not controlled at all, 5 is completely controlled
In the past 12 months, how many emergency department visits have you had due to asthma (that did not result in a hospitalization)?
In the past 12 months, how many inpatient hospitalizations have you had due to asthma?
Calculation
If your score is 19 or less, your asthma may not be under control.

If you are wanting to schedule a visit to discuss with Dr. Lauren further, you can sign up through the website: anchorintide.com

If you are wanting to first have a free meet and greet with Dr. Lauren, you can schedule one here: Free Meet and Greet
Name

First NameLast Name
Email
example@example.com
Copyright 2002, by QualityMetric Incorporated.
Asthma Control Test is a trademark of QualityMetric Incorporated.
The Asthma Control Test is for people with asthma 12 years and older.

References: 1. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). NIH Item 08-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed September 10, 2007. 2. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.
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Asthma Control Test&trade; Is:

For Patients 12 Years and Older:

Asthma Control Test™ Is: