Asthma Review Form (Dec 2024)

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.

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

Email Address
Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)? (optional)

Yes

No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? (optional)

Yes

No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? (optional)

Yes

No

How often do you need to use your reliever inhaler? (optional)

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

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? (optional)

Yes

No

Since your last review, have you needed a course of steroid tablets to get your asthma under control? (optional)

Yes

No

Do you smoke? (optional)

Yes

No

Did you have a flu vaccination last flu season? (optional)

Yes

No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?) (optional)
Asthma Control Score

During the past 4 weeks, how often did your asthma hinder your activity at work, school or home?

All of the time - 1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

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

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

Not at all - 5

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 or more times a week - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

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

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

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

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5
Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA

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Asthma Review Form (Dec 2024)

Asthma Review Form (Dec 2024)

Your Details

Asthma Review

Asthma Control Score

Consent