Asthma Control Test – Adults Asthma Control Test – Adults What is your name? What is your date of birth? MM slash DD slash YYYY Does your asthma prevent you from getting as much done at work/school/home?1 – All of the time2 – Most of the time3 – Some of the time4 – A little of the time5 – None of the timeHave you had shortness of breath?1- Multiple times a day2 – Once a day3 – 3-6 times a week4 – 1-2 times a week5 – NeverDo your asthma symptoms wake you up at night or early in the morning?1 – 4+ times a week2 – 2-3 times a week3 – Once a week4 – Once or twice5 – NeverHave you used your reliever inhaler (usually blue)?1 – 3+ times a day2 – 1-2 times a day3 – 2-3 times a week4 – Once a week5 – NeverHow would you rate your asthma control?1 – Not controlled2 – Poorly controlled3 – Somewhat controlled4 – Well controlled5 – Completely controlled
