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Asthma review (aged 12 and over)

Asthma Review (aged 12 and over)

How often does your asthma cause symptoms during the day?
How often does your asthma cause symptoms at night?
How often does your asthma limit your activities?
Does your asthma have any specific triggers?
What triggers your asthma?

Asthma Control Score

During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home?
During the last 4 weeks, how often have you had shortness of breath?
During the last 4 weeks, how often has your asthma symptoms woken you up at night or earlier than usual in the morning?
During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication?
How would you rate your asthma control during the last 4 weeks?

Smoking status

Do you currently smoke?
How many cigarettes do you smoke per day?
Have you ever smoked?
How many cigarettes did you smoke per day before you quit?
Do you use an electronic cigarette (vape)?
Have you ever used an electronic cigarette (vape)?
Are you regularly exposed to second hand tobacco smoke?
Where are you exposed to second hand tobacco smoke?
Do you know what inhalers you use and how to use them?
Do you know what to do if your asthma gets worse?
Are you happy for your asthma review to be marked as complete?

What happens next?

Once you click Submit below, this form will be submitted to the practice and passed on to our asthma team to review.

Depending on your answers, they will either:

  • Mark your asthma review as complete
  • Ask reception to contact you to arrange an appointment

To ensure that you have a full asthma review at least once a year, you will be asked to complete this form every year during your birth month.