CBC Asthma Control Test ages 12 and older Asthma Control Test Ages 12 and older Child's Name* First Last Child's Date of Birth* MM slash DD slash YYYY Name of Person Completing Form* First Last Relationship to Child* Today's Date* MM slash DD slash YYYY This form will provide a score that will help your nurse practitioner determine if your child’s asthma treatment plan is working or if it might be time for a change.Have your child answer the following questions that best applies to their asthma symptoms:1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at school or at home?* None of the time A little of the time Some of the time Most of the time All of the time 2. During the past 4 weeks, how often have you had shortness of breath?* Not at all Once or twice a week 3-6 times a week Once a day More than once a day 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?* Not at all Once or twice Once a week 2 or 3 nights a week 4 or more nights a week 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?* Not at all Once a week or less 2 to 3 times per week 1 or 2 times per day 3 or more times per day 5. How would you rate your asthma control during the past 4 weeks?* Completely controlled Well controlled Somewhat controlled Poorly controlled Not controlled at all Total* Calculated – do not edit If your child’s score is 19 or less, it may be a sign that your child’s asthma is not controlled as well as it could be. Your nurse practitioner will discuss these results with you and your child.
