Child Asthma Review (4-11)

If you have been advised by the surgery to submit a review of your child’s asthma symptoms, please complete this form.

Child Asthma Review (4-11)

Child Asthma Review (4-11)

Please use this date format: DD/MM/YYYY.

How to take the Childhood Asthma Control Test

Let your child respond to the first four questions (1 to 4). If your child needs help reading or understanding the question, you may help, but let your child select the response.

Complete the remaining three questions (5 to 7) on your own and without letting your child’s response influence your answers. There are no right or wrong answers.

Questions for Child

How is your asthma today? *
How much of a problem is your asthma when you run, exercise or play sports? *
Do you cough because of your asthma? *
Do you wake up during the night because of your asthma? *

Questions for Parent / Guardian

During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *
During the last 4 weeks, how many days did your child wheeze during the day because of asthma? *
During the last 4 weeks, how many days did your child wake up during the night because of asthma? *