Select Yes or No for each question below. Do this just before each doctor's visit.

In the past 2 weeks

1. Have you coughed, wheezed, felt short of breath, or had chest tightness:

• During the day?

  a) Yes    b) No

• At night, causing you to wake up?

  a) Yes    b) No

• During or soon after exercise?

  a) Yes    b) No

2. Have you needed "quick-relief" medicine more than one to two times per week?

3. Has your asthma kept you from doing anything you wanted to do?

4. Have your asthma medicines caused you any problems, like shakiness, sore throat, or upset stomach?

In the past few months

5. Have you missed school or work because of your asthma?

6. Have you gone to the emergency room or hospital because of your asthma?

Questions created by the National Heart, Lung, and Blood Institute. Interactive format created by A.D.A.M., Inc.