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Asthma Control Test™ (ACT™) for Patients 12 Years of Age And Older

Caregivers of children 6-11 years old: Download the ACT™ Caregiver Report here.

Thinking your asthma is under control? Taking the Asthma Control Test™ may surprise you. Even if your rescue inhaler stops your asthma symptoms from getting worse, using it more than 2 times a week is a sign that your asthma may not be under control. And uncontrolled asthma is not okay. According to clinical guidelines from the National Heart, Lung, and Blood Institute (NHLBI)(for patients 12 years of age and older), your asthma may be considered uncontrolled if you:

  • Have 2 or more asthma attacks a year that require oral steroids
  • Wake up at night 1-3 times per week
  • Have wheezing, chest tightness, a cough, or feel out of breath 2 or more times a week

What's the ACT™ test?

The Asthma Control Test™ (ACT™)is an important five-question health survey that measures the elements of asthma control as defined by the NHLBI. ACT™ is an efficient, reliable, and valid method of measuring asthma control, with or without lung functioning measures such as spirometry.

To take the test if you are 12 years of age or older, just answer the questions below and click CALCULATE to continue to the Doctor Discussion Guide. Then print your results to share with your doctor.

To take the test if you are a caregiver of a child 6-11 years old, download and print this PDF of the ACT™ Caregiver Report.

Find out if your asthma is well-controlled right now

If your total point value is 19 or below, your asthma may not be well-controlled.
Be sure to talk to your healthcare professional about your asthma score.

Asthma Control Test Questions for Patients 12 Years of Age and Older Please answer each question to get your results

  1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
    • All of the time
    • Most of the time
    • Some of the time
    • A little of the time
    • None of the time

    You Answered:

    ---
  2. During the past 4 weeks, how often have you had shortness of breath?
    • More than once a day
    • Once a day
    • 3 to 6 times a week
    • Once or twice a week
    • Not at all

    You Answered:

    ---
  3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?
    • 4 or more nights a week
    • 2 to 3 nights a week
    • Once a week
    • Once or Twice
    • Not at all

    You Answered:

    ---
  4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as Albuterol, Ventolin®, Proventil®, Maxair®, or Primatene® Mist)?
    • 3 or more times per day
    • 1 or 2 times per day
    • 2 or 3 times per week
    • Once a week or less
    • Not at all

    You Answered:

    ---
  5. How would you rate your asthma control during the past 4 weeks?
    • Not Controlled at all
    • Poorly Controlled
    • Somewhat Controlled
    • Well Controlled
    • Completely Controlled

    You Answered:

    ---
Please answer each question to get your results

Share your Asthma Control Test Results with your doctor

To make things easier, you can add your ACT™ results for patients 12 years of age and older to your printable XOLAIR Doctor Discussion Guide so you have everything you want to discuss with your doctor in one place.

Create Your Doctor Discussion Guide

Check out the questions you can use to build your XOLAIR Doctor Discussion Guide and add your ACT™ results (for patients 12 years of age and older) too.

Get started

This survey is not a diagnostic tool. It is intended to supplement, but not replace or contradict the advice of your personal physician. If you have any questions or concerns about your health, it is always a good idea to seek one-on-one professional medical consultation.

Asthma Control Test™ (ACT™) © 2002, 2007 QualityMetric Incorporated. All rights reserved. ACT™ is a trademark of QualityMetric Incorporated. Ventolin is a registered trademark of GlaxoSmithKline. Proventil is a registered trademark of Schering-Plough Corporation. Maxair is a registered trademark of Graceway Pharmaceuticals, LLC. Primatene is a registered trademark of Armstrong Pharmaceuticals Inc.

Ask your doctor if XOLAIR may be right for you or your child

Take advantage of free tools and resources to help you start the conversation.

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    What is XOLAIR?

    XOLAIR® (omalizumab) for subcutaneous use is an injectable prescription medicine used to treat patients 6 years of age and older with moderate to severe persistent asthma whose asthma symptoms are not controlled by asthma medicines called inhaled corticosteroids. A skin or blood test is performed to see if you have allergies to year-round allergens.

    XOLAIR is not used to treat other allergic conditions, acute bronchospasm or status asthmaticus.

    IMPORTANT SAFETY INFORMATION

    What is the most important information I should know about XOLAIR?

    Severe allergic reaction. A severe allergic reaction called anaphylaxis can happen when you receive XOLAIR. The reaction can occur after the first dose, or after many doses. It may also occur right after a XOLAIR injection or days later. Anaphylaxis is a life-threatening condition and can lead to death. Go to the nearest emergency room right away if you have any of these symptoms of an allergic reaction:

    • wheezing, shortness of breath, cough, chest tightness, or trouble breathing
    • low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety, or feeling of "impending doom"
    • flushing, itching, hives, or feeling warm
    • swelling of the throat or tongue, throat tightness, hoarse voice, or trouble swallowing

    Your healthcare provider will monitor you closely for symptoms of an allergic reaction while you are receiving XOLAIR and for a period of time after your injection. Your healthcare provider should talk to you about getting medical treatment if you have symptoms of an allergic reaction after leaving the healthcare provider’s office or treatment center.

    Do not receive XOLAIR if you are allergic to omalizumab or any of the ingredients in XOLAIR.

    Before receiving XOLAIR, tell your healthcare provider about all of your medical conditions, including if you:

    • have any other allergies (such as food allergy or seasonal allergies)
    • have sudden breathing problems (bronchospasm)
    • have ever had a severe allergic reaction called anaphylaxis
    • have or have had a parasitic infection
    • have or have had cancer
    • are pregnant or plan to become pregnant. It is not known if XOLAIR may harm your unborn baby.
    • are breastfeeding or plan to breastfeed. It is not known if XOLAIR passes into your breast milk. Talk with your healthcare provider about the best way to feed your baby while you receive XOLAIR.

    Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, or herbal supplements.

    How should I receive XOLAIR?

    • XOLAIR should be given by your healthcare provider, in a healthcare setting.
    • XOLAIR is given in 1 or more injections under the skin (subcutaneous), 1 time every 2 or 4 weeks.
    • In asthma patients, a blood test for a substance called IgE must be performed prior to starting XOLAIR to determine the appropriate dose and dosing frequency.
    • Do not decrease or stop taking any of your other asthma medicine unless your healthcare providers tell you to.
    • You may not see improvement in your symptoms right away after XOLAIR treatment.

    What are the possible side effects of XOLAIR?
    XOLAIR may cause serious side effects, including:

    • See, "What is the most important information I should know about XOLAIR" regarding the risk of anaphylaxis.
    • Cancer. Cases of cancer were observed in some people who received XOLAIR.
    • Inflammation of your blood vessels. Rarely, this can happen in people with asthma who receive XOLAIR. This usually, but not always, happens in people who also take a steroid medicine by mouth that is being stopped or the dose is being lowered. It is not known whether this is caused by XOLAIR. Tell your healthcare provider right away if you have rash; chest pain; shortness of breath; or a feeling of pins and needles or numbness of your arms or legs.
    • Fever, muscle aches, and rash. Some people who take XOLAIR get these symptoms 1 to 5 days after receiving a XOLAIR injection. If you have any of these symptoms, tell your healthcare provider.
    • Parasitic infection. Some people who are at a high risk for parasite (worm) infections, get a parasite infection after receiving XOLAIR. Your healthcare provider can test your stool to check if you have a parasite infection.
    • Heart and circulation problems. Some people who receive XOLAIR have had chest pain, heart attack, blood clots in the lungs or legs, or temporary symptoms of weakness on one side of the body, slurred speech, or altered vision. It is not known whether this is caused by XOLAIR.

    The most common side effects of XOLAIR:

    • In adults and children 12 years of age and older with asthma: pain especially in your arms and legs, dizziness, feeling tired, skin rash, bone fractures, and pain or discomfort of your ears.
    • In children 6 to less than 12 years of age with asthma: common cold symptoms, headache, fever, sore throat, pain or discomfort of your ear, abdominal pain, nausea, vomiting and nose bleeds.

    These are not all the possible side effects of XOLAIR. Call your doctor for medical advice about side effects.

    You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555 or Novartis Pharmaceuticals Corporation at 888-669-6682.

    Please see full Prescribing Information, including Medication Guide for additional Important Safety Information.

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