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 date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Please answer the following questions about your asthma. The answers you give will help us to review your asthma and decide if you need to speak to a practice nurse.

Understanding Your Asthma

Information to help people understand their asthma is available on this website so you may wish to look at this before answering this question: www.nhs.uk/conditions/asthma/

Do you feel that you understand your asthma? *
Do you consent to us sending you information about your condition by SMS messaging to your mobile phone if appropriate? *

Smoking

Do you currently smoke? *
Do you wish to be sent details of how to access support to help you quit? *

Flu Vaccination

People with asthma are eligible for an NHS Flu Vaccine if they are on regular preventative treatment for their asthma or have been admitted to hospital due to asthma.

If eligible, have you had your annual flu vaccination this year? *
Would you like us to arrange for you to have a flu vaccine? *

Weight

Your Treatment

Inhaler Technique

It is important to use inhalers correctly so that you get full benefit.

Videos showing how to use different types of inhaler are available on this website: www.asthma.org.uk/advice/inhaler-videos

Do you use a spacer? *
A plastic chamber which you attach to your inhaler.
Have you replaced it in the last 12 months? *
If no we will send a prescription for a new one to your usual pharmacy.
Are you having any problems with your medication/ inhalers? *

Asthma Hospital Admissions

Have you been admitted to hospital during the last 12 months, because of your asthma? *
Have you ever been admitted to an intensive care unit (ITU/ICU) because of your asthma? *

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? *
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