Asthma Review Asthma Review Personal DetailsFull Name Date of Birth DD slash MM slash YYYY Email Please double check you’ve entered the correct email addressPhoneSecurity Question (used to identify you)In which month did you last see a doctor/nurse at this surgery?Do you take any prescribe medicines? Can you tell me what they are?Have you had an operation in hospital? Can you remember when and what it was for?Answer Asthma Control ScoreDuring the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? All of the time Most of the time Some of the time A little of the time None of the time During the past 4 weeks, how often have you had shortness of breath? More than once a day Once a day 3-6 times a week 1-2 times a week Not at all 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? 4 or more times a week 2-3 nights a week Once a week Once or twice Not at all During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? 3 or more times a day 1-2 times a day 2-3 times a week Once a week or less Not at all How would you rate your asthma control during the past 4 weeks? Not controlled Poorly controlled Somewhat controlled Well controlled Completely controlled Additional QuestionsPlease complete the additional questions below and then press submit to send your review to your Doctor.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 No Since your last review, have you needed a course of steroid tablets to get your asthma under control? Yes No Do you smoke? Yes No Did you have a flu vaccination last flu season? Yes No Do you have a peak flow meter? Yes No Are you happy with your inhaler technique Yes No Privacy Consent I consent to the practice collecting and storing my data from this form.This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.
