ASTHMA CONTROL QUESTIONNAIRE - ACQ-5 When asthma is present, this score can be useful for assessing the current level of control and to track progress over time. Date* Name* First Last DOB* 1. On average, during the past week, how often were you woken by your asthma during the night?* 0 - Never 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, during the past week, how bad were your asthma symptoms when you woke up in the morning?* 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, during the past week, how limited were you in your activities because of your asthma?* 0 - Not limited at all 1 - Very slightly limited 2 - Slightly limited 3 - Moderately limited 4 - Very limited 5 - Extremely limited 6 - Totally limited 4. In general, during the past week, how much shortness of breath did you experience because of your asthma?* 0 - None 1 - Very little 2 - A little 3 - A moderate amount 4 - Quite a lot 5 - A great deal 6 - A very great deal 5. In general, during the past week, how much of the time did you wheeze?* 0 - Not at all 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 of the time ACQ-5 score is:The score suggests "well controlled asthma"The score suggests "not well controlled asthma"The score suggests uncontrolled asthma