Asthma Questionnaire

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.

1.) In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
2.) During the past 4 weeks, how often have you had shortness of breath?
More than once a day
Once a day
3 to 6 times a week
Once or twice a week
Not at all
3.) 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?
4 or more nights a week
2 to 3 nights a week
Once a week
Once or Twice
Not at all
4.) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as Albuterol, Ventolin®, Proventil®, Maxair® or Primatene Mist®)?
3 or more times per day
1 or 2 times per day
2 or 3 times per week
Once a week or less
Not at all
5.) How would you rate your asthma control during the past 4 weeks?
Not Controlled at all
Poorly Controlled
Somewhat Controlled
Well Controlled
Completely Controlled


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 between 5 and 15, your asthma is poorly controlled and you should be seen by an MD immediately.

If your total point value is between 16 – 20, your asthma is somewhat controlled and be sure to talk to your healthcare professional about your asthma score.

You asthma is controlled if your total point value is between 21 – 25.

If you would like to make an appointment to see one of our doctors affiliated with the Asthma Institute, please call UPMC’s Comprehensive Lung Center at (412) 648-6161 and make an appointment with Drs. Sally Wenzel, Merritt Fajt, Andrej Petrov, or Marc Gauthier.

This Web site was created by the Center for Research on Health Care (CRHC) Data Center.
The site is being maintained by the University of Pittsburgh - Asthma Institute
Contact the webmaster at dcweb@pitt.edu.