Please use this form only if you have been requested to do so by the surgery. If your symptoms are deteriorating or if you have any concerns, please make an appointment with a Practice Nurse for a full review.
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Email
*
Home telephone
Mobile telephone
Since your last review, have you attended A&E or had an emergency doctor appointment 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
Ex-Smoker
Asthma Control Scheme
In the past month, how often has your asthma prevented you from getting as much done at work/school/home?
Never
A little of time
Some of the time
Most of the time
All of time
In the past month, how often have you experienced shortness of breath?
Never
Once a day
More than once a day
1-2 times a week
3-6 times a week
In the past month, how often have asthma symptoms (wheezing/coughing/chest tightness/shortness of breath) wake you up at night or earlier than usual in the morning?
Never
Once or twice
Once a week
2-3 times a week
4 or more times a week
In the past month, how often have you used your rescue inhaler or nebulizer medication?
Never
Once a week or less
2-3 times a week
1-2 times a day
3 or more times a day
How would you rate your asthma control?
Not controlled
Poorly controlled
somewhat controlled
Well controlled
Completely controlled
Do you have an asthma action plan?
Yes
No
Don't know
Submit
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