Asthma feedback form

Asthma feedback form

University Health Service, Southampton
Thank you for following the link to this form to send us up-to-date information about your current asthma situation.

We can, for many of our patients, collect this information without needing to see you, so thank you for answering the following questions.

We will use the data to update your medical record.
Do you consent to using Jotform to collect this data. This form is GDPR compliant, EU-based & secure.

Asthma feedback form

Your asthma medications
Please tell us which inhalers or drugs your CURRENTLY USING for your asthma (please do not include inhalers or drugs which you do not use normally)

Asthma feedback form

Exercise
Typically, on how many days per week is your ability to exercise affected by asthma

Asthma feedback form

Asthma review
When did you last have a face-to-face review with a nurse or doctor about your asthma?

Asthma feedback form

Your previous smoking history
When did you start smoking
Enter year
When did you stop smoking
Enter year
Typically, how many cigarettes did you used to smoke per day?
Enter number per day

Asthma feedback form

Your smoking history
When did you start smoking
Enter year
Typically, how many cigarettes do you smoke per day?
Enter number per day
Smoking, with or without asthma, is a very harmful activity. Please contact us if you need help giving up smoking.

Asthma feedback form

Review with a professional
At the moment, do you need to see a health care professional to discuss your asthma further?

Asthma feedback form

Organising review
To see someone, please call the surgery on (023) 8055 7531 and book an appointment.

Alternatively, use you personal online secure account to book an appointment at https://www.patientaccess.com/.