Asthma Questionnaire Full Name *Date of Birth *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910Do You Smoke or Vape?Currently Smoking or using a VapeNever SmokedEx SmokerDo You Smoke of Vape?Smoking AssesmentIf you smoke or vape please give details0 / 501. Question 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 timeMost of the timeSome of the timeA little of the timeNone of the timeChose one of the answers above2. Question - During the past 4 weeks, how often have you had shortness of breath? *More than once a dayOnce a day3 to 6 times a weekOnce or twice a weekNot at allChose one of the answers above3. Question - 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 week2 or 3 nights a weekOnce a weekOnce or twiceNot at allChose one of the answers above4. Question - During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? *3 or more times per day1 or 2 times per day2 or 3 times per weekOnce a week or lessNot at allChose one of the answers above5. Question - How would you rate your asthma control during the past 4 weeks? *Not controlled at allPoorly controlledSomewhat controlledWell controlledCompletelyChose one of the answers aboveFinal ScoreScore calculated after your answers.Send MessagePlease do not fill in this field.