EmailMeForm
Asthma Control Survey
GLOBAL STRATEGY FOR ASTHMA MANAGEMENT & PREVENTION 2017.
In the past four weeks, how often did your asthma prevent you from getting as much done at work, school or home?
All of the time
Most of the time
Some of the time
A little of the time
Not at all
Tick which best suits you.
During the past four weeks, how often have you had shortness of breath?
More than once a day
Once a day
3 to 6 times a week
Once or twice a day
Not at all
Tick which best suits you.
During the past four 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 times a week
2 to 3 times a week
1 night a week
Less than 1 night a week
Not at all
Tick which best suits you.
During the past four weeks, how often have you used your reliever medication (such as your blue inhaler or rescue inhaler)?
3 or more times a day
1 or 2 times a day
2 or 3 times a week
Once a week or less
Not at all
Tick which best suits you.
How would you rate your asthma control during the past four weeks?
Not controlled
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
Tick which best suits you.
Name
First
Last
Email
Contact Number. For landlines please use an extra 0 before area code e.g. Palmerston North would read 006-358-7788
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Your Score
