Asthma Control Test 12 y/o and Up

Name:

DOB:

Date:

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.
Clinically validated against spirometry and specialist assessment.

For Patients 12 Years and Older:

Answer each question and write the answer number in the box to the right of each question.
Add your answers and write your total score in the TOTAL box shown below.
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 of the time 2 - Most of the time 3 - Some of the time 4 - A little of the time 5 - None of the time

SCORE

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 to 6 times a week 4 - Once or twice a week 5 - Not at all

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?

1 - 4 or more nights a week 2 - 2 or 3 nights a week 3 - Once a week 4 - Once or twice 5 - Not at all

SCORE

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

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

SCORE

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

SCORE

TOTAL

If your score is 19 or less, your asthma may not be under control. Be sure to talk with your doctor about your results. The answers below should not be added to your total score. These answers should be discussed with your doctor.

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?

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