Asthma Review Form Asthma Review Name DrMissMrMrsMsProf.Rev. Prefix First Last Date of Birth DD MM YYYY Gender Female Male Address Street Address Address Line 2 City Post Code Email Enter Email Confirm Email Contact Number Asthma SymptomsNIGHT TIME SYMPTOMS: In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? No Yes, most nights Yes, 1-2 times per week Yes, 1-2 times in the last month If your asthma is disturbing your sleep please book a review with the asthma nurse.DAYTIME SYMPTOMS: In the last month have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? No Yes, most days Yes, 1-2 times per week Yes, 1-2 times in the last month Details of symptoms during the day: EXERCISE OR EXERTION SYMPTOMS: In the last month has your asthma interfered with your usual activities e.g. housework, work/school etc? No Yes, most days Yes, 1 to 2 times per week Yes, 1 to 2 times in the last month If you have answered "yes" to any of the above questions, i.e. you have had any symptoms in the last month, please make an appointment for a face to face review.Details: Peak FlowDo you know your best PEFR (peak flow) value ? Inhaler UseWhat's the name of your inhaler and how often do you use it? How often do you use your blue inhaler? Daily Weekly Monthly Annually Details of inhaler use: Are you happy with your inhaler technique? Yes No There is an online demonstration on the Asthma UK website… https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/ 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.