Asthma Review Form

This form is for patients who are due an Annual Asthma Review.

Please answer the questions on the form below and then click submit for your answers to be sent to your practice.

If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or your GP.

Q1. When was your asthma diagnosed?


Less than 5 years agoMore than 5 years agoMore than 10 years ago
Q2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including coughs)?


NoYes, everydayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a yearYes, see below for details:
Q3. In the last month, have you had your usual asthma symptoms during the day? (eg. a cough, wheezing, chest tightness or breathlessness)


NoYes, everydayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a yearYes, see below for details:
Q4. How often do you use your blue inhaler?


DailyWeeklyMonthlyAnnuallyOther, see details below:
Q5. In the last month, has your asthma interfered with your usual activities (eg. housework, work, school etc.)?


YesNo
Q6. Have you ever had your Peak Flow measured at the surgery?


YesNo
If yes, do you know your best PEFR value?


Q7. Are you happy with your inhaler technique? There is an online demonstration on the Asthma UK website, or you could pop into your surgery for advice.


YesNo
Q8. Have you ever smoked?


YesNo
If yes, how many do you smoke each day?


If no, when did you quit?


There are plenty of options available to help you quit smoking. Is this something you would like us to contact you about?


YesNo

For an appointment or clinical advice, contact your practice