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How much of the time did you have trouble breathing today? | None of the time | A little of the time | Some of the time | A good bit of the time | Most of the time | All of the time |
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Circle one number
| 0 | 1 | 2 | 3 | 4 | 5 |
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How much did your asthma bother you today? | Did not bother me | Bothered me a little | Bothered me somewhat | Bothered me a good deal | Bothered me very much | Bothered me as much as possible |
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Circle one number
| 0 | 1 | 2 | 3 | 4 | 5 |
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How much of the time did your asthma limit your activity today? (activities include any sort of physical activity: running, playing, jumping, sports, bike-riding, gym, etc.) | None of the time | A little of the time | Some of the time | A good bit of the time | Most of the time | All of the time |
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Circle one number
| 0 | 1 | 2 | 3 | 4 | 5 |
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Night time awakening question
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Were you woken by asthma? (either during the night or in the morning) | No | Once | More than once | Awake all night | | |
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Circle one number
| 0 | 1 | 2 | 3 | | |