Asthma Control test ACT for people 12 years and older Asthma Control test ACT for people 12 years and older If you are human, leave this field blank. Name * Address * Date of birth * Email Address Please complete the following questions and click "submit" at the bottom of the page when complete. These questions look at your asthma control. Depending on your answers, we may invite you in for a review. 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 1 - All of the time 2- Most of the time 3 -Some of the time 4 - A little of the time 5 - None of the time 2. During the past 4 weeks, how often have you had shortness of breath? 1 - More than once a day 2 -Once a day 3 - 3 to 6 times a week 4 - Once or twice a week 5 - Not at all 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? 1 - 4 or more nights a week 2 - 2 or 3 nights a week 3 - Once a week 4 - Once or twice 5 - Not at all 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 1 - 3 or more times per day 2 - 1 or 2 times per day 3 - 2 or 3 times per week 4 - Once a week or less 5 - Not at all 5. How would you rate your asthma control during the past 4 weeks? 1 - Not controlled at all 3 - Poorly controlled 3 - Somewhat controlled 4 - Well controlled 5 - Completely controlled Please leave this blank Submit Please click here to complete the smoking status questionnaire.