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 an appointment with our Nurse.

Asthma Review

Asthma Review

About You

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

Your Asthma Review

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 normal in the morning?
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
During the past 4 weeks, how often have you had shortness of breath?
How would you rate your asthma control during the past 4 weeks?
Since your last review have you needed to see a doctor as an emergency or attend A&E department of a hospital or be admitted to hospital because of your asthma?
Since your last review have you needed a course of steroid tablets to get your asthma under control?
N.B. Please ensure you list what you are actually using which may not necessarily be what you are prescribed.
In the last 3 months have you considered reducing your asthma medication?
Do you smoke?
If you are interested in giving up smoking, our practice nurses will be able to offer help and support. Please make an appointment with the nurse for “smoking cessation”.

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