Score each: Not at all, Mildly, Moderately, Severely, Very Severely.

1.)   “I have been troubled by a cough”

           not at all__    mildly__   moderately__   severely__    very severely__

2.)   “Asthma has limited my performance at work, school or other activities.”

 not at all__    mildly__   moderately__   severely__    very severely__

3.)   “I have worried about my present or future health because of asthma.”

           not at all__    mildly__   moderately__   severely__    very severely__

4.)   “I have been troubled by episodes of shortness of breath.”

          not at all__    mildly__   moderately__   severely__    very severely__

5.)   “I have been restricted in walking up hills or doing heavy housework because of my asthma.”

          not at all__    mildly__   moderately__   severely__    very severely__

6.)   “ I have felt frustrated with myself and my condition.”

      not at all__    mildly__   moderately__   severely__    very severely__

7.)   “I have felt congested”

           not at all__    mildly__   moderately__   severely__    very severely__

8.)   “ I have felt that asthma is controlling my life.”

           not at all__    mildly__   moderately__   severely__    very severely__

9.)   “I have been limited in going certain places because of my asthma.”

           not at all__    mildly__   moderately__   severely__    very severely__

10.)                       “ I have been troubled by wheezing attacks.”

           not at all__    mildly__   moderately__   severely__    very severely__

11.)                       “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:____________________________