Asthma Review Form Asthma Review Title MrMrsMissMsMxSirDrProfFirst Name Surname Date of Birth Day Month Year Gender Female Male Address* Street Address Address Line 2 City Post Code Email Enter Email Confirm Email Contact Number Asthma SymptomsIn the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or home? Please SelectAll of the timemost of the timeSome of the timeA little of the timeNone of the timeDuring the past 4 weeks, how often have you had shortness of breath? Please SelectMore than once a dayOnce a day3 - 6 times per week1 - 2 times a weekNot at allDuring the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? Please Select4 or more times a week2 - 3 nights a weekOnce a weekOnce or twiceNot at allDuring the past 4 weeks, how often have you used your rescue inhaler or nebuliser medication? Please Select3 or more times a day1 - 2 times a day2 - 3 times a weekOnce a week or lessNot at all(Usually the blue inhaler)How would you rate your asthma control during the past 4 weeks? Please SelectUncontrolledPoorly controlledSomewhat controlledWell controlledCompletely ControlledDetails: Peak FlowDo you know your best PEFR (peak flow) value ? Inhaler UseWhat preventor inhaler do you use? How many puffs do you take and how often?” How often do you use your reliever (usually blue inhaler)? Daily Weekly Monthly Annually Details of inhaler use: Are you happy with your inhaler technique? Yes No Video Guides: How to use your inhaler Smoking StatusDo you smoke? Yes No Ex-Smoker When did you stop? How many cigarettes do you smoke a day? Would you like help to quit smoking? Yes No Thank you for completing your online asthma review. Depending on the answers you have given we may need to request that you have a follow up appointment with a nurse. You are also welcome to arrange a face to face appointment to discuss your asthma whenever you wish.