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Asthma

These are usually six-monthly. Please bring your inhalers so that your inhaler technique can be checked. Asthma causes much suffering, hospital admissions and even deaths, all of which are preventable with modern treatments. Telephone reviews may be suitable for some patients.

Fill in the form below before your annual review.

Your details

Full name(Required)

First name(s) Last name

Date of birth(Required)

Day

Month

Year

NHS number

Get help to find your NHS number online

Asthma review

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?(Required)

All of the time

Most of the time

Some of the time

A little of the time

None of the time

During the past 4 weeks, how often have you had shortness of breath?(Required)

More than once a day

Once a day

3 to 6 times a week

Once or twice a week

Not at all

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?(Required)

4 or more nights a week

2 to 3 nights a week

Once a week

Once or twice

Not at all

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?(Required)

3 or more times per day

1 or 2 times per day

2 or 3 times per week

Once a week or less

Not at all

How would you rate your asthma control during the past 4 weeks?(Required)

Not controlled at all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

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Asthma control score

How many asthma exacerbations have you had in the past 12 months?(Required)

An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention (for more information follow this link)

Do you have any further information about your asthma that you feel is relevant to this review?

Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery.

What is your smoking status?(Required)

Current smoker

Ex-smoker

Never smoked

How much do you smoke?(Required)

Less than 1 cigarettes per day or equivalent

1-9 cigarettes per day or equivalent

10-19 cigarettes per day or equivalent

20-30 cigarettes per day or equivalent

40+ cigarettes per day or equivalent

Quitting smoking

Smoking leads to health problems such as cancer, heart disease and strokes. The benefits of stopping smoking include: better health, more money and cleaner air for those around you!

Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: NHS quit smoking website

Does anyone else in your household smoke? (if patient is 19 years old or younger)(Required)

Yes

No

Who smokes in your household? (if patient is 19 years old or younger)

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Date published: 14th March, 2025
Date last updated: 14th March, 2025

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