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RÉSEAU QUÉBÉCOIS
DE L ASTHME
ET DE LA M.P.O.C.
Asthma Symptoms Diary
My Asthma Quiz
Every night, I put a checkmark next to the symptoms that affected me TODAY.
Today, did I cough, wheeze,
Days of the month
or have a hard time breathing…
1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1
1) During daytime
2) Enough to wake me up at night
3) Enough to use my blue pump
(record number of times per day)
4) Enough to make me do less physical
activity or sports
5) Enough to miss school, regular
activities, or work
6) Enough to go to a clinic or a hospital without an appointment
Number of checkmarks
Today, my asthma is :
The number of checkmarks on My Asthma Quiz indicates my level of asthma control.
E X 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1
UNDER CONTROL : 0 or 1 checkmark
NOT WELL CONTROLLED :
checkmarks per day anytime, or 1 or more checkmarks
per day on 4 or more days in a 7-day period
OUT OF CONTROL : My blue pump does
My Asthma Medications*
I record the total number of puffs/pills for each medication that I took TODAY.
*Details on back
E X 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1
Control medication: ___________
(To reduce inflammation)
Relief medication: ___________
(To open airways)
Other medication: __________________
Other medication: __________________
Other Symptoms/Triggers
I record this information and I put a checkmark if it applies to me TODAY.
1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1
(ex.: runny nose, contact with allergens) Collaboration of the Research institute of McGill University Health Centre Registration of Copyright Library and Archives Canada, 2008 - Registration of Copyright Library and National Archives of Quebec, 2008 My peak flow (If my health professional hasn’t talked to me about it, then it does not apply to me.)
Using the peak flow meter :
Personal notes
1 I put the indicator to zero (0).
2 I hold the peak flow meter horizontally.
3 I take a deep breath.
4 I put the mouthpiece in my mouth, and I tighten
5 I blow as hard and as quickly as possible
Adresso graph
6 I do this exercise 3 times, and I record the highest
reading value in the graph.
Asthma medications :
· The control medication stabilizes asthma and prevents asthma symptoms. I should take it everyday as recommended by
the doctor. It is often found in an orange, brown, red or purple pump or in a pill. There are different brands of control
medications (e.g.Flovent , Pulmicort , Symbicort ,
Alvesco , Advair , Singulair , Accolate , etc.).
· The relief medication relieves my asthma symptoms. I should take it only when I have asthma symptoms or before
exercising. The relief medication is mostly found in a blue pump. There are different brands of relief medications
(e.g. Ventolin , Bricanyl ,
For more information on asthma, I may contact le Réseau québécois de l’asthme et de la MPOC
Web site : www.rqam.ca
Phone number : 1 877 441-5072
My health care professional :
All rights reserved. Any modification of the format or contents of this document is forbidden without the written authorization of the author. Any request for reproduction must be forwarded to the Réseau québécois de l'asthme et de la MPOC (RQAM) www.rqam.ca

Source: http://www.rqam.ca/stock/fra/14-asthmasymptomsdiary.pdf