In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or 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

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

           1-- more than one day
           2-- once a day
           3-- 3 to 6 times a week
           4-- once or twice a week
           5-- not at all

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 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

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

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

Add your answers and write your score in the total box. If your score is 19 or less, your asthma may not be controlled as well as it could be. 

To be on the safe side, print this page out and bring it to your next doctor's appointment with us.