Asthma Review

For patients who are due an annual asthma review.

Please would you answer the questions on the form below and submit it 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.

Asthma Review Form

You are due an 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.

Name
Date
Address

Questionnaire

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?
Have you ever had your peak flow measured at the surgery?
ml/min
Are you happy with your inhaler technique?
Have you ever smoked?
If 'Yes' Do you smoke now?
If 'No' when did you quit?
There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Asthma Control Score