Step 1 of 8 12% Asthma Control Questionnaire (ACQ) (Symptoms Only) Click the 'Next' button below to get started. English version for Australia TM ©The Asthma Control Questionnaire (ACQ) is copyrighted and all rights are reserved. No part of this questionnaire may be sold, modified or reproduced in any form without the express permission of Elizabeth Juniper on behalf of QOL Technologies Limited. Please answer questions 1 - 5. Select the response that best describes how you have been in the last week. 1. On average, in the last week, how often were you woken by your asthma during the night? 1. On average, in the last week, how often were you woken by your asthma during the night?(Required) 0 - Not at all 1 - Hardly ever 2 - A few times 3 - Several times 4 - Many times 5 - A great many times 6 - Unable to sleep because of asthma 2. On average, in the last week, how were your asthma symptoms when you woke up in the morning?2. On average, in the last week, how were your asthma symptoms when you woke up in the morning?(Required) 0 - No symptoms 1 - Very mild symptoms 2 - Mild symptoms 3 - Moderate symptoms 4 - Quite severe symptoms 5 - Severe symptoms 6 - Very severe symptoms 3. In general, in the last week, how limited were you in your day-to-day activities because of your asthma? 3. In general, in the last week, how limited were you in your day-to-day activities because of your asthma?(Required) 0 - Not at all limited 1 - Very slightly limited 2 - Slightly limited 3 - Moderately limited 4 - Very limited 5 - Extremely limited 6 - Totally limited 4. In general, in the last week, how much shortness of breath did you experience because of your asthma? 4. In general, in the last week, how much shortness of breath did you experience because of your asthma?(Required) 0 - None 1 - Very little 2 - A little 3 - A moderate amount 4 - Quite a lot 5 - A great deal 6 - An extreme amount 5. In general, in the last week, how often did you wheeze? 5. In general, in the last week, how often did you wheeze?(Required) 0 - None of the time 1 - Hardly any of the time 2 - A little of the time 3 - A moderate amount of the time 4 - A lot of the time 5 - Most of the time 6 - All the time To receive your Asthma Score and a copy of your Asthma Control Questionnaire responses, please enter your details below:First Name(Required)Last Name(Required)Email Address (Primary Contact, Parent or Adult)(Required) Year of birth(Required)State(Required)ACTNSWNTQLDSATASVICWAPostcode(Required)This field is hidden when viewing the formToday's Date YYYY slash MM slash DD This field is hidden when viewing the formScoreThis field is hidden when viewing the formScore CategoryWell Controlled (<= 0.75), Partially Controlled (>0.75, <=1.5), Not Well Controlled (>1.5)This field is hidden when viewing the formScore CategoryWell Controlled (<= 0.75), Partially Controlled (>0.75, <=1.5), Not Well Controlled (>1.5)This field is hidden when viewing the formScore CategoryWell Controlled (<= 0.75), Partially Controlled (>0.75, <=1.5), Not Well Controlled (>1.5)NameThis field is for validation purposes and should be left unchanged. For any information on the use of the electronic ACQ, please contact Mapi Research Trust, Lyon, France. Internet: https://eprovide.mapi-trust.org © 2017 QOL TECHNOLOGIES LTD.
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