Asthma Review Form

You will find lots of useful information at Asthma & Lung UK.

Asthma Review (Crewe Medical)
Please use format day/month/year e.g. 12/05/1979
During the last 4 weeks, how often have you had shortness of breath?
During the last 4 weeks, how often have you used your reliever inhaler (usually blue inhaler)?
During the last 4 weeks, how often have your asthma symptoms interfered with your day to day activities?
In the last 4 weeks, have you had difficulty sleeping due to your asthma?
How would you rate your asthma control during the last 4 weeks?
Are you happy with your inhaler technique and feel that you are able to use them correctly and appropriately?
Your smoking status
Would you like a nurse to call you to discuss your Asthma?

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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.