ASTHMA CONTROL SCORE QUESTIONAIRE - (ACQ5)

Studies show that approximately 50% of people with Asthma have poor control and their Asthma can affect their day to day activities. Don Medical Clinic is using "The Asthma Control Test" (ACQ5) is a test you can take yourself to assess how well your asthma is controlled. This version for ages 11 and over. Children under 11 should be assessed by their GP.

Please complete this survey. A copy of your results will be sent to our clinic for review.

Please answer questions 1 - 5.

Select the response that best describes how you have been in the last week .

First Name *

Last Name *

Patient Age? *This is the age of the patient with Asthma the test is for

Your Personal Email Address *

Your usual GP

Q1. On average, in the last week, how often were you woken by your asthma during the night? *

Q1 *

0 - Not at all1 - Hardly Ever2 - A Few Times3 - Several times4 - Many times5 - A great many times6 - unable to sleep

Q2 *

0 - No Symptoms1 - Very Mild Symptoms2 - Mild Symptoms3 - Moderate Symptom4 - Quite Severe Symptoms5 - Severe Symptom6 - Very Severe Symptoms

Q2. On average, in the last week, how were your asthma symptoms when you woke up in the morning?

Q3 *

0 - Not at all limited1 - Very slightly limited2 - slightly limited3 - Moderately limited4 - Very Limited5 - Severely limited6 - Totally Limited

3. In general, in the last week, how limited were you in your day-to-day activities because of your asthma?

Q4 *

0 - None1 - Very Little2 - a Little3 - a Moderate amount4 - Quite a lot5 - A great Deal6 - An extreme amount

4. In general, in the last week, how much shortness of breath did you experience because of your asthma?

Q5 *

0 - None of the time1 - Hardly any of the time2 - a Little of the time3 - a Moderate amount of the time4 - a lot of the time5 - Most of the time6 - All the time

5. In general, in the last week, how often did you wheeze?

Asthma Control Score

Your score is indicates your Asthma is

WELL CONTROLLED ,

you should see your GP regularly for a general Asthma Review.

You can all the clinic on 03 6441 5299 (Mon to fri. 9am to 5pm)

Or can book online through the link at https://www.hotdoc.com.au/request/appointment/patient?clinic=don-medical-clinic

Your score indicateS your Asthma is

PARTIALLY CONTROLLED ,

you should see your GP for an Asthma Review.

You can all the clinic on 03 6441 5299 (Mon to fri. 9am to 5pm)

Or can book online through the link at https://www.hotdoc.com.au/request/appointment/patient?clinic=don-medical-clinic

Your score shows your Asthma is

POORLY CONTROLLED,

you should see your GP for an urgent Review to assess your Asthma

You can all the clinic on 03 6441 5299 (Mon to fri. 9am to 5pm)

Or can book online through the link at https://www.hotdoc.com.au/request/appointment/patient?clinic=don-medical-clinic

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