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? | Score | ||||
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All of the time ①| Most of the time ② | Some of the time ③ | A little of the time ④ | None of the time ⑤ | |
2. During the past 4 weeks, how often have you had shortness of breath? | |||||
More than once a day ①| Once a day ② | 3 to 6 times a week ③ | Once or twice a week ④ | Not at all ⑤ | |
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 ①| 2 or 3 nights a week ② | Once a week ③ | Once or twice ④ | Not at all ⑤ | |
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 ①| 1 or 2 times per day ② | 2 or 3 times per week ③ | Once a week or less ④ | Not at all ⑤ | |
5. How would you rate your asthma control during the past 4 weeks? | |||||
Not controlled at all ①| Poorly controlled ② | Somewhat controlled ③ | Well controlled ④ | Completely controlled ⑤ |