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Asthma Patient Questionnaire


This one-page asthma questionnaire can be completed by the patient before a visit to the physician's office or used for case management of high-risk asthma patients. This tool is available in English and Spanish and can be printed in black and white or color.

This tool contains 12 questions on topics such as overall rating of condition, activity limitations, symptoms, hospital visits/stays, and medications. The patient is also asked to indicate his or her interest in receiving additional information on specific asthma-related topics.


Oregon Department of Human Services, Oregon Asthma Program

Funding Sources

Centers for Disease Control and Prevention

QualityTool Topic



  • Release Date: 04/2005
  • Original Summary: 06/2007
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.

Last updated: April 14, 2008.