Asthma Review Form

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 contact the surgery.

Last Updated: 06/11/2020

Your Details

Name *

Date of Birth *

Phone Number

Email Address

Asthma Review

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, shortness of breath, chest tightness or pain) wake you up at night or earlier in the morning? *

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication? *

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

How many asthma exacerbations have you had in the past 12 months? (An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.) *

Do you have any further information about your asthma that you feel is relevant to this review? (Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP.)

What is your smoking status? *

If you are a current smoker, how much do you smoke?

If you are aged 19 years or younger, does anyone else in your household smoke?

Yes

If you answered yes to the question above, who smokes in your household?

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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Asthma Review Form

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