FREE – That catches everyone’s eye!!!

Below is an intake questionnaire for you to fill out regarding you or your family member’s asthma. Fill out the material and email back in to us- We will review and give comments on how you/your family member’s asthma is controlled. We recommend you take/email the intake to your provider for consideration in your current care.

Include an Asthma Control Test (ACT) questionnaire (links below) would really help us and your provider!

Adult ACT questionnaire:

Child ACT questionnaire: (don’t forget to have the child answer the kid’s portion- with faces).

Intake questionnaire BLANK


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