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.

Asthma Review

Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Asthma Review

Please complete the following questions to allow your health care professional to assess your asthma.

The questionnaire is for a routine review of your symptoms. If you are experiencing sever shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

How often does your asthma cause symptoms during the day? *
How often does your asthma cause symptoms at night? *
How often does your asthma limit your activities? *

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler videos below to check that you are using your inhalers correctly:
Please select the types of inhalers that you use: *

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

Lifestyle - Alcohol

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day drinking? Please see www.drinkaware.co.uk *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Lifestyle - Smoking

Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?
For further information, please see: www.nhs.uk/smokefree

Asthma Control Test Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
How often have you had shortness of breath? *
How often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
How often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control? *