Asthma Control Questionnaire
Please complete this form to help assess your current asthma control over the past week.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
In the past week, how often have you experienced the following asthma symptoms?
*
Rows
Never
Once or twice
2-3 times
4 or more times
Shortness of breath
1
2
3
4
Wheezing
5
6
7
8
Coughing
9
10
11
12
Chest tightness
13
14
15
16
Waking up at night due to asthma
17
18
19
20
Have you had any asthma attacks in the past 4 weeks?
*
No
Yes, 1 time
Yes, 2 or more times
How often have you used your rescue inhaler (quick-relief medication) in the past week?
*
Not at all
1-2 times
3-6 times
Daily
Have your asthma symptoms limited your activities (work, school, exercise) in the past week?
*
Not at all
A little
Moderately
Severely
Do you know of any triggers that worsened your asthma in the past week? (Select all that apply)
Allergens (dust, pollen, pets)
Exercise
Cold air
Respiratory infection
Smoke or pollution
Other
Are you currently taking any daily asthma control medications?
*
Yes
No
On a scale from 1 to 5, how would you rate your overall asthma control during the past week?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Please provide any additional comments or information about your asthma.
Submit Assessment
Should be Empty: