Take the Asthma Control Test™ (ACT) for people 12 yrs and older.

Patient's Name

Today's Date

Address

City/State/Zip

Know your score. Share your results with your doctor.

Step 1 Write the number of each answer in the score box provided.

Step 2 Add the score boxes for your total.

Step 3 Take the test to the doctor to talk about your score.

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 time (1) Most of the time (2) Some of the time (3) A little of the time (4) None of the time (5)

Score

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

More than once a day (1) Once a day (2) 3 to 6 times a week (3) Once or twice a week (4) Not at all (5)

Score

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 week (1) 2 or 3 nights a week (2) Once a week (3) Once or twice(4) Not at all (5)

Score

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 day (1) 1 or 2 times per day (2) 2 or 3 times per week (3) Once a week or less (4) Not at all (5)

Score

5. How would you rate your asthma control during the past 4 weeks?

Not controlled at all (1) Poorly controlled (2) Somewhat controlled (3) Well controlled (4) Completely controlled (5)

Score

Total

If your score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your doctor.

FOR PHYSICIANS:

The ACT is:

A simple, 5S-question tool that is self administered by the patient
Recognized by the National Institutes of Health
Clinically validated by specialist assessment and spirometry

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