Asthma - Blackburn Road Medical Centre

Contact Details

Name

Full Address (including postcode)

Date of Birth

Home Phone

Mobile Phone

Email Optional

Questionnaire

When were you diagnosed? Optional

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

Details of sleeping difficulties: Optional

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

Details of symptoms during the day: Optional

If yes, do you know your best PEFR value Optional

If 'Yes' how many do you smoke each day? Optional

If 'No' when did you quit? Optional

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 reliever inhaler (usually blue)?

How would you rate your asthma control during the past 4 weeks?

Asthma Annual Review Questionnaire

Contact Details

Questionnaire

Asthma Control Score