Self Assessment for Asthma
Choose the best answer and add up the number of points associated with it.
Number of points per column |
1 |
2 |
3 |
4 |
5 |
In the past 4 weeks, how much time did your asthma keep you from getting as much done at work, school or at home? |
All the time |
Most of the time |
Some of the time |
A little of the time |
None of the time |
During the past 4 weeks, how often have you had shortness of breath? |
More than once a day |
Once a day |
3-6 times a week |
Once or twice a week |
Not at all |
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 |
2-3 nights per week |
Once a week |
Once or twice |
Not at all |
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 or 2 times per day |
2 or 3 times per week |
Once a week or less |
Not at all |
How would you rate your asthma control during the past 4 weeks? |
Not controlled at all |
Poorly controlled |
Somewhat controlled |
Well controlled |
Completely controlled |
If you have 19 points or less, your asthma is NOT well controlled and it is important that you see a provider as soon as possible. Call 650-3400 for an appointment or see your own doctor within the next 2-3 days.
