This survey was designed to help you describe your asthma and how your asthma affects how you feel
and what you are able to do. To complete it, please select the radio button that best describes your answer.
Each response to the 5 ACT questions has a point value from a 1 to 5 as shown on the form. To score the ACT, add up the point values for each response to all five questions.
If your total point value is 19 or below, your asthma may not be well-controlled. Be sure to talk to your
healthcare professional about your asthma score.
Take this survey to your healthcare professional and talk about your asthma treatment plan.
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