Childhood Asthma Control Test For Children 4 To 11 Years Template
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Childhood Asthma Control Test for children 4 to 11 years.
This test will provide a score that may help the doctor determine if your child’s asthma treatment plan is working or if it might be time for a change.
How to take the Childhood Asthma Control Test
Step 1 Let your child respond to the first four questions (1 to 4). If your child needs help reading or understanding the question, you may
help, but let your child select the response. Complete the remaining three questions (5 to 7) on your own and without letting your
child’s response influence your answers. There are no right or wrong answers.
If your child’s score is 19 or less, it
Step 2 Write the number of each answer in the score box provided.
19
may be a sign that your child’s
Step 3 Add up each score box for the total.
asthma is not controlled as well
or less
Step 4 Take the test to the doctor to talk about your child’s total score.
as it could be. Bring this test to
the doctor to talk about the results.
Have your child complete these questions.
1. How is your asthma today?
SCORE
0
1
2
3
Very bad
Bad
Good
Very good
2. How much of a problem is your asthma when you run, exercise or play sports?
1
0
2
3
It's a big problem, I can't do what I want to do. It's a problem and I don't like it.
It's a little problem but it's okay.
It's not a problem.
3. Do you cough because of your asthma?
1
0
2
3
Yes, all of the time.
Yes, most of the time.
Yes, some of the time.
No, none of the time.
4. Do you wake up during the night because of your asthma?
0
1
3
Yes, all of the time.
Yes, most of the time.
Yes, some of the time.
No, none of the time.
Please complete the following questions on your own.
5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
5
4
3
2
2
1
0
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
5
4
2
1
0
3
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
7. During the last 4 weeks, how many days did your child wake up during the night because of asthma?
5
4
3
2
1
0
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
TOTAL
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