1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much work done at work, school, or 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 per day

• Once per day

• 3 to 6 times per week

• Once or twice per 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 per week

• 2 or 3 nights per week

• Once per 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)?

• 3 or more times per day

• 1 to 2 times per day

• 2 or 3 times per week

• Once per 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