How is your Asthma?

DD slash MM slash YYYY
During the past 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home?
During the last 4 weeks, how often have you had shortness of breath?
During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning?
During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)?
How would you rate your asthma control during the last 4 weeks?
How many exacerbations of your Asthma have you had in the last 12 months?
Are you confident with your inhaler technique?
This field is for validation purposes and should be left unchanged.

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