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.