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

• None of the time
• A little of the time
• Some of the time
• Most of the time
• All of the time

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

• Not at all
• Once or twice a week
• 3 to 6 times a week
• Once a day
• More than once a day

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, or chest tightness) wake you up at night or earlier than usual in the morning?

• Not at all
• Once or twice
• Once a week
• 2 to 3 nights a week
• 4 or more nights a week

During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol, Ventolin, Proventil, Maxair, or Primatene Mist)?

• Not at all
• Once a week or less
• 2 or 3 times per week
• 1 or 2 times per day
• 3 or more times per day

How would you rate your asthma control during the past 4 weeks?

• Completely controlled
• Well controlled
• Somewhat controlled
• Poorly controlled
• Not controlled at all

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Survey adapted from Nathan R et al. Development of the Asthma Control Test: A survey for assessing asthma control. J Allergy Clin Immunol. 2004;113:59-65.

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Asthma Control Test^™ is a trademark of QualityMetric Inc.

Ventolin^®, Proventil^®, Maxair^™, and Primatene^® Mist are registered trademarks of their respective owners.