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.

Asthma Review

You can send us your Annual Asthma Review by completing this form. If your symptoms are deteriorating or you have any concerns please also make an appointment to see the respiratory nurse.

About You

Date

Your Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?
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)?
Since your last review, have you needed to see a doctor as an emergency or attend the Accident and Emergency (A&E) department of a hospital as a result of your asthma?
Have you been prescribed oral steroids to control your asthma since your last review?
Have you ever had your peak flow measured at the surgery?
Are you happy with your inhaler technique?
Do you smoke?

Privacy

Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly.
This field is for validation purposes and should be left unchanged.