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? All of the time Most of the time Some of the time A little of the time None of the time 2. During the past 4 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 week 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? 4 or more nights a week 2 or 3 nights a week Once a week Once or twice Not at all 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 or 2 times per day 2 or 3 times per week Once a week or less Not at all 5. How would you rate your asthma control during the past 4 weeks? Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled Please enter your ZIP code:      Why my ZIP Code? Reset Form

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