Today’sDate:
Patient’sName:
Childhood Asthma Control Testfor children 4to11 years.
Thistestwill provideascorethatmayhelpthe doctordetermineifyourchild’sasthmatreatmentplanisworkingorifitmightbetimeforachange.
Howtotake theChildhood AsthmaControlTest
Step1Letyourchildrespondtothefirstfourquestions(1to4).Ifyourchildneedshelpreadingorunderstandingthequestion,youmay help,butletyourchildselecttheresponse.Completetheremainingthreequestions(5to7)onyourownandwithoutlettingyour child’sresponseinfluenceyouranswers.Therearenorightorwronganswers.
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
Step2Writethenumberofeachanswerinthescoreboxprovided.
Step3Addupeachscoreboxforthetotal.
Step4Takethetesttothedoctortotalkaboutyourchild’stotalscore.
Have your child answerthesequestions.
1.Howisyourasthmatoday?
19
orless
Ifyourchild’sscore is19orless,it maybeasign that yourchild’s asthmaisnotcontrolledaswell asitcouldbe.Bringthistestto
thedoctortotalkabouttheresults.
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
SCORE
0123
VerybadBadGoodVerygood
2.Howmuchofaproblemisyourasthma whenyourun,exerciseorplaysports?
0123
It'snotaproblem.
3.Doyoucoughbecauseofyourasthma?
0123
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
Yes,allofthetime.Yes,mostofthetime.
4.Doyouwakeupduring thenight becauseofyourasthma?
Yes,someofthetime.
No,noneofthetime.
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
013
Yes,allofthetime.Yes,mostofthetime.Yes,someofthetime.No,noneofthetime.
Pleasecomplete thefollowingquestions onyour own.
5.Duringthelast4weeks,howmanydaysdidyourchildhaveanydaytimeasthmasymptoms?
543210
Notatall1-3days4-10days11-18days19-24daysEveryday
6.Duringthelast4weeks,howmanydaysdidyourchild wheezeduring thedaybecauseofasthma?
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
543
210
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
Notatall1-3days4-10days11-18days19-24daysEveryday
7.Duringthelast4weeks,howmanydaysdidyourchildwakeupduringthenightbecause ofasthma?
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
543
210
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12
TOTAL
Three Visit Model Tool Kit: Appendix 9
Asthma Control Test for Children age 4-12