Asthma Review Form

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

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

More than once a day

Once a day

Once a week

More than once a week

During the last 4 weeks, how often have you used your reliever inhaler (usually blue inhaler)?

Three or more times a day

1-2 times a day

Once a week or less

During the last 4 weeks, how often have your asthma symptoms interfered with your day to day activities?

Never

Daily

1-2 times per week

1-2 times per month

In the last 4 weeks, have you had difficulty sleeping due to your asthma?

Never

1-2 nights a week

Most nights

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

Poorly controlled

Somewhat controlled

Well controlled

Approximately how many asthma exacerbations (flare ups) do you feel you have had in the past 12 months?

Are you happy with your inhaler technique and feel that you are able to use them correctly and appropriately?

Yes

Your smoking status

Smoker

Ex Smoker

Never Smoked

User of E-Cigarette

Would you like a nurse to call you to discuss your Asthma?

Yes

Privacy Policy

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.

I consent to the practice collecting and storing my data from this form.

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