Asthma Control Questionnaire (ACQ) (Symptoms Only)

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English version for Australia

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©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.

Who is completing this Asthma Control Questionnaire?(Required)

Please select one of the above options

About the teen adolescent child in your care

What is their name?(Required)

Please type the name of the teen (aged 12–17) you’re filling out this Asthma Control Questionnaire for.

What is their year of birth?(Required)

Please enter the year of birth for the teen (aged 12–17) you’re completing this Asthma Control Questionnaire for.

Please answer questions 1 - 5.
Have them select the response that best describes how their asthma has 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

Great! You are almost done.
By completing the Asthma Control Questionnaire today for the person you care for, you’re now in the running to win an air purifier as part of Asthma Australia's Attack Asthma campaign.

Please enter your best contact details below to receive the Asthma Control Score results and next steps. If you're one of the lucky winners of the air purifier competition, Asthma Australia will contact you using the email and phone number you provide.

About you the parent caregiver

First Name(Required)

Last Name(Required)

Email(Required)

*Please DO NOT use your child's email address

Phone Number(Required)

Please DO NOT enter your child's phone number

State(Required)

Postcode(Required)

Do you have asthma questions?

Tick below to speak with an Asthma Educator—it's a free service from Asthma Australia.

Would you like to be contacted by an Asthma Educator?(Required)

Yes I would like an Asthma Educator to contact me

No I do not want to speak to an Asthma Educator just yet

Great! You are almost done.

To get a copy of your Asthma Control Questionnaire results, you need to provide some basic contact details.

If you're under 18, we need to know that a parent or guardian says it's okay for us to send you information about asthma and your Asthma Control Questionnaire.

If you're not sure what that means, it's a good idea to check with a parent or guardian before sharing your details.

First Name(Required)

Last Name(Required)

What year were you born?(Required)

What State do you live in?(Required)

Please select one of the dropdown options

Postcode

If you know your postcode, enter it here.

Email Address(Required)

Heads up! If you're under 18 and using your own email, we’ll assume you’ve got permission from your parent or guardian to get emails from Asthma Australia about your Asthma Control Questionnaire.

Permission to send information to someone under 18(Required)

Yes, I have consent from my parent, carer or guardian

No, I do not have consent from parent, carer or guardian

Thank you for completing the Asthma Control Questionnaire. Click the 'submit' button below and your results will be on their way to your email.