Asthma Review Form - Wycliffe Medical Practice

Title*

First Name*

Surname*

Date of Birth*

Gender*

Female

Male

Address*

Street Address Address Line 2 City Post Code

Email*

Enter Email Confirm Email

Contact Number*

Asthma Symptoms

In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or home?*

During the past 4 weeks, how often have you had shortness of breath?*

During 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?*

During the past 4 weeks, how often have you used your rescue inhaler or nebuliser medication?*(Usually the blue inhaler)

How would you rate your asthma control during the past 4 weeks?*

Details:*

Peak Flow

Do you know your best PEFR (peak flow) value ?*

Inhaler Use

What 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 Status

Do 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.