Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Please be advised, you will still need to have a face to face appointment with the nurse every 12 months.

Asthma Review

Asthma Review

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Can we contact you by email?

Yes

No

Can we contact you by text message?

Yes

No

Your Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?

Yes

No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes

No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes

No

How often do you need to use your reliever inhaler?

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes

No

Please give details:

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes

No

Do you smoke?

Yes

No

Did you have a flu vaccination last flu season?

Yes

No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?):

Please note that the details you give will be used to update your medical records.

*

I confirm that the information provided is accurate to the best of my knowledge.