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Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
Blog
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Online Appointment
Online Appointment
online Appointment
Forms
Asthma Control
Questionnaire Form
FORMS
Fill all required fields (★) to submit the form.
Patient details:
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number
(Required)
Home Phone:
Address:
Email address
(Required)
Height:
(Required)
Weight:
(Required)
Please answer questions 1 -5. Choose the number of the response that best describes how you have been in the last week.
1. On average, in the last week, how often were you woken by your asthma during the night?
(Required)
0: Not at all
1: Hardly ever
2: A few times
3: Several times
4: Many times
5: A great many times
6: Unable to sleep because of asthma
2. On average, in the last week, how were your asthma symptoms when you woke up in the morning?
(Required)
0: No symptoms
1: Very mild symptoms
2: Mild symptoms
3: Moderate symptoms
4: Quite severe symptoms
5: Severe symptoms
6: Very severe symptoms
3. In general, in the last week, how limited were you in your day-to-day activities because of your asthma?
(Required)
0: Not at all limited
1: Very slightly limited
2: Slightly limited
3: Moderately limited
4: Very limited
5: Extremely limited
6: Totally limited
4. In general, in the last week, how much shortness of breath did you experience because of your asthma?
(Required)
0: None
1: Very little
2: A little
3: A moderate amount
4: Quite a lot
5: A great deal
6: An extreme amount
5- In general, in the last week, how often did you wheeze?
(Required)
0: None of the time
1: Hardly any of the time
2: A little of the time
3: A moderate amount of the time
4: A lot of the time
5: Most of the time
6: All the time
Scoring:
Confirm:
(Required)
I confirm that the above information is complete and correct.
(Required)
