Asthma Review

Could you please complete all fields of this form otherwise it may have to be rejected and a new form completed.

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Please be aware that Peak Flow readings are required as part of this form.

Further Information:

Asthma Review

Asthma Review

About You

Have you received a letter, text message or verbal invitation to complete this assessment? *
Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.
For each inhaler please tell us how many times each day you use the inhaler and how many puffs of the inhaler you use.
Do you use a spacer when using your inhalers? *
Have you had any asthma exacerbations this year for which you have been prescribed steroid tablets (prednisolone) for your chest? *
Have you had any overnight hospital admissions relating to your lungs in the past 12 months? *
Do you cough up phlegm/sputum? *
Has this changed since your last review? *
How often? *
Is this a new for you in the past 12 months? *

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent 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, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *