Children's Asthma Review Form

This form is used for your childs (6-12 years) annual asthma review. Please answer the questions and submit this form to us. If your childs symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.

Last Updated: 09/02/2022

Your Child's Details

Asthma Review

4 to 11 year olds - Asthma Control Score

This test will provide a score that may help your doctor determine if your child’s asthma treatment plan is working or if it might be time for a change.

How to take the Childhood Asthma Control Test

Step 1 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.

Step 2 Write the number of each answer in the score box provided.

Step 3 Add up each score box for the total.

Step 4 Take the test to the doctor to talk about your child’s total score.

Please complete the following questions on your own.