Asthma review

Asthma annual review

Please only fill out this form if you have been asked to by the practice. This questionnaire is for routine annual review of your Asthma. Please complete the form to the best of your ability and when you are happy with all your answers, click submit below and the questionnaire will be automatically sent to the practice. Depending on your answers, you will be contacted if you need to be seen in the practice for further assessment. Should your symptoms change, please seek medical advice and book an appointment if required. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Name

First Last

Date of birth

Address

Inhaler technique - I have watched the below relevant inhaler technique video in the weblink below and am happy with my inhaler technique

For everyone with COPD or asthma, it is essential to have good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly. COPD Foundation Videos https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Educational-Video-Series.aspx

Smoking

please select the option that best fits you

Do you use an e-cigarette or vape?

Smoking makes asthma worse. Please follow this link to get help to quit smoking

1 - In the past 4 weeks, how often did your asthma prevent you from getting as much done at work/school/home?(Required)

These questions are only for those 12 years and older. They allow us to calculate a score to determine if your asthma is well controlled.

2 - In the past 4 weeks, how often have you had shortness of breath?

3 - In the past 4 weeks, how often did your asthma symptoms wake you up at night or early in the morning?

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

5 - How would you rate your asthma control?

Asthma Control Test Score TOTAL

Please calculate your total score out of 25 by adding up the 5 parts of the asthma control test.

Any questions/concerns (optional)

Use the box above to enter any issues that you would like to raise with our clinical pharmacist or GP.

Cookies on this website

Drs Foster, Logan, and Macdonald

Asthma review

Asthma annual review