ITG Asthma Short Form Scoring Demonstration

These statements describe the way in which asthma (or its treatment) affects some people. Please select the response to each statement that most closely applies to you over the past 4 weeks.

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.
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 felt tired or a general lack of energy.
Not at all Mildly Moderately Severely Very severely

10. I have felt sad or depressed.
Not at all Mildly Moderately Severely Very severely

11. I have been limited in going to certain places because they are bad for my asthma.
Not at all Mildly Moderately Severely Very severely

12. I have been troubled by wheezing attacks.
Not at all Mildly Moderately Severely Very severely

13. I have felt that asthma is preventing me from achieving what I want in life.
Not at all Mildly Moderately Severely Very severely

14. I have felt anxious, under tension or stressed.
Not at all Mildly Moderately Severely Very severely

15. I have been unable to breathe.
Not at all Mildly Moderately Severely Very severely