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Asthma Control Test (ACT)

Asthma Control Test (ACT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


AsthmA Control test


Know your score
The Asthma Control Test

provides a numerical score to help you and your healthcare
provider determine if your asthma symptoms are well controlled.
Take this test if you are 12 years or older. Share the score with your healthcare provider.
Step 1: Write the number of each answer in the score box provided.
Step 2: Add up each score box for the total.
Step 3: Take the completed test to your healthcare provider to talk about your score.
If your score is 19 or less, your asthma symptoms may not be as well controlled as they could be. No matter
what the score, bring this test to your healthcare provider to talk about the results.
Name: Today’s Date:
2. During the past 4 weeks, how often have you had shortness of breath?
More than
Once a day [1]
Once
a day [2]
3 to 6 times
a week [3]
Once or
twice a week [4]
Not at all [5]
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 [1]
2 to 3 nights
a week [2]
Once a
week [3]
Once or
twice [4]
Not at all [5]
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]
1 or 2 times
per day [2]
2 or 3 times
per week [3]
Once a week
or less [4]
Not at all [5]
5. How would you rate your asthma control during the past 4 weeks?
Not Controlled
at All [1]
Poorly
Controlled [2]
Somewhat
Controlled [3]
Well
Controlled [4]
Completely
Controlled [5]
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 [1]
Most of
the time [2]
Some of
the time [3]
A little
of the time [4]
None of
the time [5]
SCORE
If your score is 19 or less, your asthma symptoms may not be as well controlled
as they could be. No matter what your score is, share the results with your
healthcare provider.
TOTAL:
Copyright 2002, by QualityMetric Incorporated.
Asthma Control Test is a trademark of QualityMetric Incorporated.
This material was developed by GSK.
2014 GSK group of companies.
All rights reserved. Produced in USA. 80108R0 December 2014