Asthma Control Questionnaire © - Launceston Sleep Centre

Date

Please complete your personal information below.

First Name *

First

Last Name *

Last

Email

Phone *

Date of birth *

Gender *

M

F

Are you an existing patient? *

Yes

No

For each question below, please select the response that best describes how you have been in the last week.

On average, in the last week, how often were you woken by your asthma during the night? *

On average, in the last week, how were your asthma symptoms when you woke up in the morning? *

On average, in the last week, how limited were you in your day-to-day activities because of your asthma? *

On average, in the last week, how much shortness of breath did you experience because of your asthma? *

On average, in the last week, how often did you wheeze? *