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Asthma review

If you have been advised by the surgery to submit an annual review of your asthma symptoms, please submit this form.

If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Full name

Date of birth

Phone number

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

Yes

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? Yes No

Yes

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

Yes

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

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

Yes

Do you smoke?

Yes

Did you have a flu vaccination last flu season?

Yes

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.

Consent for storing submitted data