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Alba Medical Group - Coatbank
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Asthma Control Test
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Adult Control Test for Adult 12+ years
Adult Control Test for Adult 12+ years
Asthma Control Test – Adult
First Name
*
Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Control Test Questions
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?
*
All of the time – 1
Most of the time – 2
Some of the time – 3
A little of the time – 4
None of the time – 5
During the last 4 weeks, how often have you had shortness of breath?
*
More than once a day – 1
Once a day – 2
3-6 times a week – 3
1-2 times a week – 4
Not at all – 5
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?
*
4 or more times a week – 1
2-3 nights a week – 2
Once a week – 3
Once or twice – 4
Not at all – 5
During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication?
*
3 or more times a day – 1
1-2 times a day – 2
2-3 times a week – 3
Once a week or less – 4
Not at all – 5
How would you rate your asthma control during the last 4 weeks?
*
Not controlled – 1
Poorly controlled – 2
Somewhat controlled – 3
Well controlled – 4
Completely controlled – 5
If you are human, leave this field blank.
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