Asthma ACT Questionnaire

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Personal Details

As part of your asthma care, we would like to gather up to date information about some aspects of your asthma. It should take no longer than three minutes to complete.

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May be used to identify you

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Please answer the following questions

Are you 19 years old or younger?: *

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?: *

During the past 4 weeks, how often have you had shortness of breath?: *

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?: *

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?: *

How would you rate your asthma control during the past 4 weeks?: *

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How many asthma exacerbations have you had in the past 12 months?

An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention (for more information see here).

Please note that your answers will not be seen immediately, and you should direct any urgent queries to us via Reception.

Smoking Status

Please note that ‘smoking status’ refers to smoking tobacco products, and not the use of e-cigarettes or ‘vaping’. If you only use e-cigarettes or ‘vape’ then please select ‘Ex-smoker’ (if you used to smoke tobacco smoker) or ‘Never smoked’.

What is your smoking status?: *

How much do you smoke?: *

If you smoke something other than traditional cigarettes (e.g. roll-your-own or cigars) but you aren’t sure what the equivalent in cigarettes is, please just select your best guess.

Does anyone else in your household smoke?: *

Please check this box to submit your answers.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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