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

If you are human, leave this field blank.

Section

Your Asthma Review

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *

All of the time - 1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

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

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

Not at all - 5

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 usual in the morning? *

4 or more times a week - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

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

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

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

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5

Calculated Asthma Score:

In the last month have you had difficulty sleeping due to your asthma (including cough)?

Yes

No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes

No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes

No

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes

No

Please give details:

How many asthma exacerbations have you had in the past 12 months?

An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention (for more information see NHS: Asthma attacks)

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes

No

What is your smoking status?

Current smoker

Ex smoker

Never smoked

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

How much do you smoke?

Less than 1 cigarette per day or equivalent

1-9 cigarettes per day or equivalent

10-19 cigarettes per day or equivalent

20-30 cigarettes per day or equivalent

40+ cigarettes per day or equivalent

Does anyone else in your household smoke? (if the patient is 19 years old or younger)

Yes

No

Who smokes in your household?

Did you have a flu vaccination last flu season?

Yes

No

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explantion

Do you have any further information about your asthma that you feel is relevant to this review? Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery.

*

I confirm that the information provided is accurate to the best of my knowledge