Asthma Review

For patients who are due an annual asthma review.

Please would you answer the questions on the form below and submit it to us.

If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well.

Name *

Address *

Email Address *

Date of Birth *

Postcode *

Home Phone *

Please do not include spaces

Mobile Phone *

Please do not include spaces

When was your asthma diagnosed? * Less than 5 years agoMore than 5 years agoMore than 10 years ago

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? * NoYes

Details of sleeping difficulties *

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? * NoYes

Details of symptoms during the day *

How often do you use your blue inhaler? * DailyWeeklyMonthlyAnnuallyOther, see below for details

Details of inhaler use *

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? *

No

Yes

Have you ever had your peak flow measured at the surgery? *

No

Yes

If yes, do you know your best PEFR value

(ml/min)

Are you happy with your inhaler technique? *

No

Yes

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice respiratory nurse for more advice.

Have you ever smoked? *

No

Yes

Do you smoke now? *

No

Yes

IF 'Yes' howmany do you smoke each day?

If 'No' when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about? *

No

Yes