Forms – Asthma Control Test ages 12+ – Child and Family Agency

Asthma Control Test Ages 12 and older

Child's Name*

First Last

Child's Date of Birth*

Name of Person Completing Form*

First Last

Relationship to Child*

Today's Date*

This form will provide a score that will help your nurse practitioner determine if your child’s asthma treatment plan is working or if it might be time for a change.

Have your child answer the following questions that best applies to their asthma symptoms:

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

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

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

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

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?*

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

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?*

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

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

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

Total*

Calculated – do not edit

If your child’s score is 19 or less, it may be a sign that your child’s asthma is not controlled as well as it could be. Your nurse practitioner will discuss these results with you and your child.