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

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.

Phone Number:

Email Address: *

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.

Your Asthma Review

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

Yes

No

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

Yes

No

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

Yes

No

How often do you need to use your reliever inhaler?

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?

Yes

No

Please give details:

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

Yes

No

Do you smoke?

Yes

No

Did you have a flu vaccination last flu season?

Yes

No

Please select the types of inhalers that you use: *

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explantion

*

I confirm that the information provided is accurate to the best of my knowledge