Last Updated: 27/04/2021

This form is used for your annual asthma review. Please answer the questions and submit this form 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.

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YOUR DETAILS

Date of Birth Required
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ASTHMA REVIEW

In the last month have you had difficulty sleeping due to your asthma (including cough)? Required
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? Required
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? Required
How often do you need to use your reliever inhaler? Required
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? Required
Since your last review, have you needed a course of steroid tablets to get your asthma under control? Required
Are you a Smoker Required
Did you have a flu vaccination last flu season? Required
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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? * Required
During the past 4 weeks, how often have you had shortness of breath? * Required
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? Required
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? Required
How would you rate your asthma control during the past 4 weeks? Required
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Consent

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 

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