Questionnaire for Adults (18 years & older)

Using a fast-acting inhaler to get relief from asthma attacks
does not necessarily mean you have your asthma under control.
Answer the questions below and discuss them with your doctor.

Instructions

• Click on the answer that best describes your situation.
• Your score will be automatically tallied.
• Print this page and give it to your doctor at your next visit.

Your Name

(This will be printed with your questionnaire results.)

Question 1

In the past 4 weeks, did you:

a.

Miss any work, school, or normal daily activity because of your asthma?

Yes No Unsure

b.

Wake up at night because of asthma?

Yes No Unsure

c.

Believe that your asthma was well controlled?

Yes No Unsure

Question 2

Do you use an inhaler for quick relief from asthma symptoms?

Yes No Unsure

If yes, in the past 4 weeks, what was the highest
number of puffs in 1 day you took of the inhaler? 0 5 to 8 puffs* More than 12 puffs 1 to 4 puffs 9 to 12 puffs*

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Questionnaire for Adults (18 years & older)

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