Asthma 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 deteriorating, or you are having any concerns, please make a face to face appointment with our Nurse.

If you have received a letter inviting you to make an appointment for an asthma review, please do so. Depending on the type of medication you currently use, it is not always appropriate to submit the review form online. You will need to see or speak to a GP or nurse if you have been asked to.

Asthma Review

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Your Asthma Review

Please select your smoking status.

Smoker

Non-Smoker

Ex-Smoker

In the last month have you had difficulty sleeping due to your Asthma symptoms (including cough)? *

Yes

No

In the last month have you been troubled by Asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? *

Yes

No

In the last month has your Asthma interfered with your usual activities (e.g., housework, work, school etc.)? *

Yes

No

The number of exacerbations of Asthma in the past 12 months:

Asthma Control Test

During 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? *

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

Total Score:

Out of 25

Please note that the details you give will be used to update your medical records.