Asthma Review

OPENING HOURS

Monday - Friday	8:00 - 18:30
Find your NHS number - NHS

Location

Asthma Review

I 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.

Full Name

Address

Date of Birth

Home Number

Mobile No

Post Code

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

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

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

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

6. Are you happy with your inhaler technique?

NoYes

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

7. Have you ever smoked?

NoYes

If 'Yes', please answer the following:

8. Do you smoke now?

NoYes

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?