Summervale Surgery

Canal Way, Ilminster, Somerset, TA19 9FE

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Telephone: 01460 52354

Out of Hours: 111

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Asthma Control Assessment Test

Asthma Control Assessment Test

A member of the clinical team may ask you to complete this form prior to your Asthma review.

Name

First Last

Date of birth

DD slash MM slash YYYY

Contact phone number

Question 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 (Score 1)

Most of the time (Score 2)

Some of the time (Score 3)

A little of the time (Score 4)

None of the time (Score 5)

Select one checkbox only

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

More than once a day (Score 1)

Once a day (Score 2)

3-6 times a week (Score 3)

Once or twice a week (Score 4)

Not at all (Score 5)

Select one checkbox only

Question 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 (Score 1)

2-3 nights a week (Score 2)

Once a week (Score 3)

Once or twice (Score 4)

Not at all (Score 5)

Select one checkbox only

Question 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 (Score 1)

1 or 2 times per day (Score 2)

2 or 3 times per week (Score 3)

Once a week or less (Score 4)

Not at all (Score 5)

Select one checkbox only

Question 5. How would you rate your asthma control during the past 4 weeks?

Not controlled at all (Score 1)

Poorly controlled (Score 2)

Somewhat controlled (Score 3)

Well controlled (Score 4)

Completely controlled (Score 5)

Select one checkbox only

Comments

This field is for validation purposes and should be left unchanged.

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Opening Times

Monday
08:00 until 20:00
Tuesday
08:00 until 18:30
Wednesday
08:00 until 18:30
Thursday
08:00 until 18:30
Friday
08:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

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Asthma Control Assessment Test

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