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.

Annual Review

Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day?
Has your asthma interfered with your usual daily activities (e.g. school, work, housework)?
In the last month have you has difficulty sleeping due to your asthma (including cough)?

Asthma History

How often do you need to use your reliever inhaler?
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?
Since your last review, have you needed a course of steroid tablets to get your asthma under control?
Do you Smoke?
Did you have a flu vaccination last flu season?

Inhalers

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): *

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, 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? *
During the past 4 weeks, how often have you used your rescue inhaler (usually blue) or nebulizer medication (e.g. albuterol)? *
How would you rate your asthma control during the past 4 weeks? *