preloader

Print out this page and fill in the answers once a month. Keep track of your progress to get an idea of how well your treatment is progressing.

Score each: Not at all, Mildly, Moderately, Severely, Very Severely.

    1. “I have been troubled by a cough”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “Asthma has limited my performance at work, school or other activities.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have worried about my present or future health because of asthma.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have been troubled by episodes of shortness of breath.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have been restricted in walking up hills or doing heavy housework because of my asthma.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “ I have felt frustrated with myself and my condition.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have felt congested”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “ I have felt that asthma is controlling my life.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have been limited in going certain places because of my asthma.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “ I have been troubled by wheezing attacks.”

not at all__    mildly__   moderately__   severely__    very severely__

    1. “I have been unable to breathe.”

not at all__    mildly__   moderately__   severely__    very severely__

Current Peak Expiratory Flow reading: __________________________________

Best Ever Peak Expiratory Flow reading: ________________________________

Name:___________________________

Date:____________________________

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