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?*

All of the timeMost of the timeSome of the timeA little of the timeNone of the time
2. During the past 4 weeks, how often have you had shortness of breath?*

More than once a dayOnce a day3 to 6 times a weekOnce or twice a weekNot 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?*

4 or more nights a week2 or 3 nights a weekOnce a weekOnce or twiceNot at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?*

3 or more times per day1 or 2 times per day2 or 3 times per weekOnce a week or lessNot at all
5. How would you rate your asthma control during the past 4 weeks?*

Not controlled at allPoorly controlledSomewhat controlledWell controlledCompletely controlled
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: