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Childhood Asthma Control Test (cACT)

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


SCORE
5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
Please complete the following questions on your own.
7. During the last 4 weeks, how many days did your child wake up during the night because of asthma?
Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday
Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday
2
Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday
5 4 3 2 1 0
25 4 3 2 1 0
25 4 3 2 1 0
TOTAL
1. How is your asthma today?
Have your child complete these questions.
Very bad Bad Good Very good
0 1 2 3
2. How much of a problem is your asthma when you run, exercise or play sports?
3. Do you cough because of your asthma?
4. Do you wake up during the night because of your asthma?
It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem.
0 2 31
Yes, all of the time. Yes, most of the time. No, none of the time.
0
Yes, some of the time.
2 31
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.
0 2 31
Know your score.
Parent or Guardian: The Childhood Asthma Control Test* is a way to help your child’s healthcare provider determine if your child’s asthma symptoms are well controlled.
Childhood Asthma Control Test for children � to �� years
Take this test with your child (ages 4 to 11). Share the results with your child’s healthcare provider.
Step 1: Have your child answer the �rst four questions (1 to 4). If your child needs
help, you may help, but let your child choose the answer.
Step 2: Answer the last three questions (5 to 7) on your own. Don’t let your child’s
answers in�uence yours.

There are no right or wrong answers.
Step 3: Write the number of each answer in the score box to the right.
Step 4: Add up each score box for the total.
Step 5: Take the COMPLETED test to your child’s healthcare provider to talk about your
child’s total score.
If your child’s score is 19 or less, your
child’s asthma symptoms may not be
as well controlled as they could be. No
matter what the score, bring this test
to your child’s healthcare provider to
talk about your child’s results.
19
or less
*The Childhood Asthma Control Test was developed by GSK.
This material was developed by GSK.
?2014 GSK group of companies.
All rights reserved. Produced in USA. 80109R0 December 2014
Today’s Date:
Patient’s Name: