Childhood Asthma Control Test (C-ACT) "*" indicates required fields Step 1 of 11 9% Welcome! Thank you for taking some time to complete the Asthma Control Test – you will only need about 5 minutes or so to go through it. The Asthma Control Test is a commonly used tool by healthcare providers globally and has been scientifically tested with hundreds of people with asthma. It is also a way to help you, and your doctor determine if your asthma symptoms are well controlled. Based on your score, your doctor can help you take appropriate action to better manage your asthma. There are two parts to this test. PART 1 – To be completed by yourself and the child PART 2 – To be completed by just yourself HiddenToday's Date YYYY dash MM dash DD About you (Adult parent, caregiver or guardian)This section is to be completed by yourself and the child together. There are 4 questions in this first section.First Name* Last Name* Email* Relationship to child*ParentCaregiver or GuardianStateACTNSWNTQLDSATASVICWAPostcode About the childFirst Name* Last Name* Year of Birth* PART 1 – TO BE COMPLETED BY THE CHILD WITH YOUR ASSISTANCELet your child respond to the first four questions (1 to 4). If your child needs help in reading or understanding the question, you may help, but let your child select the response by clicking on the appropriate image.Q1. How is your asthma today?* Very bad Bad Good Very good 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 Q3. Does your asthma make you cough?* Yes, all the time Yes, most of the time Yes, sometimes No, never Q4. Does your asthma make you wake up during the night?* Yes, all the time Yes, most of the time Yes, sometimes No, never PART 2 – ADULT PARENT, CAREGIVER ONLYComplete the remaining three questions (5 to 7) on your own and without letting your child’s responses influence your answers. There are no right or wrong answers.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 NOTE: If your child’s score is 12 or less, his or her asthma may be very poorly controlled. Regardless of your child’s score, continue to talk to your healthcare provider. There may be more you and your child’s healthcare provider could do to help control your child’s asthma symptoms.
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