Asthma Review - The Atherstone Surgery

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.

Asthma Annual Review Form

Asthma Annual Review Questionnaire

Your Contact Details

Title

Name

First Last

Date of Birth

Contact Number

Enter Email Confirm Email

Address

Street Address Address Line 2 City County / State / Region Post Code

Questionnaire

When was your asthma diagnosed?

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

How often do you use your blue inhaler? Optional

Details of inhaler use:

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?

If yes, do you know your best PEFR value

Are you happy with your inhaler technique?

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.

Have you ever smoked?

If ‘Yes’, please answer the following:

Do you smoke now?

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

If 'No' when did you quit? 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?

For more information on asthma click here.