Asthma Review Form

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.

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YOUR DETAILS

Name*
Date of Birth*

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)?*
How often do you need to use your reliever inhaler?*
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?*
Since your last review, have you needed a course of steroid tablets to get your asthma under control?*
Do you smoke?*
Did you have a flu vaccination last flu season?*

ASTHMA CONTROL SCORE

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?*
Consent*