Asthma Adult Control Test

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Asthma Adult Control Test

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FOR PATIENTS:

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

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.

Name:(*)

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Email address(*)

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Address(*)

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Today's date(*)

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Patient’s Name(*)

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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

Most of the time

Some of the time

A little of the time

None of the time

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

More than once a day

Once a day

3 to 6 times a week

Once or twice a week

Not at all

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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

2 or 3 nights a week

Once a week

Once or twice

Not at all

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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 or 2 times per day

2 or 3 times per week

Once a week or less

Not at all

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

Not controlled all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

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Asthma control test score:

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Captcha(*)

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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, 5-question tool that is self-administered by the patient
Recognized by the National Institutes of Health
Clinically validated by specialist assessment and spirometry¹

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