CBC Asthma Control Test ages 4-11 Asthma Control Test Ages 4-11 Years Old 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. Let your child respond to the first four questions (1 to 4). If your child needs help understanding the question, you may help, but let your child select the response. Complete the remaining three questions (5 to 7) on our own and without letting your child’s responses influence your answers. There are no right or wrong answers. Have your child answer the following questions:1. How is your asthma today?* Very Good Good Bad Very Bad 2. How much of a problem is your asthma when you run, exercise, or play sports* It’s not a problem It’s a little problem, but its okay It’s a problem and I don’t like it It’s a big problem, I can’t do what I want to do 3. Do you cough because of your asthma?* No, none of the time Yes, some of the time Yes, most of the time Yes, all of the time 4. Do you wake up during the night because of your asthma?* No, none of the time Yes, some of the time Yes, most of the time Yes, all of the time Please answer the following questions on your own:5. During the last 4 weeks, how many days did your child have any daytime asthma symptoms?* Not at all 1-3 days 4-10 days 11-18 days 19-24 days Every day 6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?* Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday 7. During the last 4 weeks, how many days did your child wake up during the night because of asthma?* Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday 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.
