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Childhood Asthma Control Test

for children 4 to 11 years old

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Today's Date
YYYY dash MM dash DD

Firstly, who are you completing the Childhood Asthma Control Test for?
Enter the details of the child below.
Child's First Name*
Child's Last Name*
Child's Year of Birth*

Have the child complete this question
Q1. How is your asthma today?*

Very bad

Bad

Good

Very good

Have the child complete this question
Q2. How much of a problem is your asthma when you run, exercise or play sports?*

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 bit of a problem but it's okay

It's not a problem

Have the child complete this question
Q3. Does your asthma make you cough?*

Yes, all the time

Yes, most of the time

Yes, sometimes

No, never

Have the child complete this question
Q4. Does your asthma make you wake up during the night?*

Yes, all the time

Yes, most of the time

Yes, sometimes

No, never

Please complete the following questions with the parent/carer
Q5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?*

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day
Q6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?*

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day
Q7. During the last 4 weeks, how many days did your child wake up during the night because of asthma?*

None

1 to 3 days

4 to 10 days

11 to 18 days

19 to 24 days

Every day

Asthma Score*
Score Category 1
Score Category 2
Score Category 3
ASTHMA SCORE CATEGORIES

- If the child’s score is less than or equal to 12, his or her asthma may be very poorly controlled.
- If score is greater than 12 or less than or equal to 20, they are not well controlled
- If the score is greater than 20, the child's asthma is well controlled.

You are almost done! Now you just need to enter your details and the details of the parent/caregiver below.
Once details have been entered, Asthma Australia will email you both a copy of the questions, responses and asthma score from today's Childhood Asthma Control Test.
Health Professional Details
Health Professional First Name*
Health Professional Last Name*
Health Professional Email*

Would you like the parent/caregiver to speak to an Asthma Educator?*

Yes

No
Parent, Caregiver or Guardian Details
Parent or Caregiver First Name*
Parent or Caregiver Last Name*
Parent or Caregiver Email*

Parent or Caregiver Phone Number
For any information on the use of the electronic C-ACT, please contact Mapi Research Trust, Lyon, France.
Internet: https://eprovide.mapi-trust.org

Childhood Asthma Control Test (C-ACT) Health Professional Version

C-ACT Health Professional Version

Childhood Asthma Control Test

for children 4 to 11 years old

Firstly, who are you completing the Childhood Asthma Control Test for?

You are almost done! Now you just need to enter your details and the details of the parent/caregiver below.

Health Professional Details

Parent, Caregiver or Guardian Details