Asthma & Medication Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are significantly deteriorating or you are having any concerns please make a telephone appointment with our Nurse.

You may have received a text or a letter. This is because asthma reviews are an essential way of monitoring your symptoms and ensuring your medication is safe and appropriate.

Asthma Information Zone Low mood & depression questionnaire

Asthma & Medication Review

Step 1 of 3

Full Name Required

Date of Birth Required

Contact Number (preferably mobile) Required

Email Required

How often does your asthma cause symptoms during the day? Required

How often does your asthma cause symptoms at night? Required

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? Required

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

During the past 4 weeks, how often have you had shortness of breath? Required

How often does your asthma limit your activities? Required

On average, how many times a week do you need to use your reliever inhaler (Blue salbutamol/Ventolin inhaler)? Required

How many asthma exacerbations have you had in the past 12 months? RequiredAn exacerbation is where your symptoms got worse AND your reliever did NOT help and you needed to seek urgent medical attention

Smoking History Required

Is there anyone in your household who smokes? Required

Yes

Do you have any further information about your asthma that you feel is relevant to this review? OptionalPlease note that your answer will not be seen immediately and you should direct any URGENT queries to reception.

Do you have an Asthma care plan? If so, when was it last reviewed? Required

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Asthma & Medication Review

Asthma & Medication Review

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