Print out this page and fill in the answers once a month. Keep track of your progress to get an idea of how well your treatment is progressing.
Score each: Not at all, Mildly, Moderately, Severely, Very Severely.
- “I have been troubled by a cough”
not at all__ mildly__ moderately__ severely__ very severely__
- “Asthma has limited my performance at work, school or other activities.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have worried about my present or future health because of asthma.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have been troubled by episodes of shortness of breath.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have been restricted in walking up hills or doing heavy housework because of my asthma.”
not at all__ mildly__ moderately__ severely__ very severely__
- “ I have felt frustrated with myself and my condition.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have felt congested”
not at all__ mildly__ moderately__ severely__ very severely__
- “ I have felt that asthma is controlling my life.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have been limited in going certain places because of my asthma.”
not at all__ mildly__ moderately__ severely__ very severely__
- “ I have been troubled by wheezing attacks.”
not at all__ mildly__ moderately__ severely__ very severely__
- “I have been unable to breathe.”
not at all__ mildly__ moderately__ severely__ very severely__
Current Peak Expiratory Flow reading: __________________________________
Best Ever Peak Expiratory Flow reading: ________________________________
Name:___________________________
Date:____________________________
