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.

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

Asthma Review

Asthma Review

Section

Your Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)? *
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *

Asthma Control Test

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 had shortness of breath? *
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? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *

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.
Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery
What is your smoking status? *
How much do you smoke? *
If the patient is under 19, does anyone else in their household smoke?

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

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