About This Form

You are due an annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.

Fields marked with an asterisk are
compulsory.

Note:
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

    Asthma Annual Review Questionnaire

    Personal Details

    Questionnaire

    ml/min

    If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

    If 'Yes', please answer the following:

    Asthma Control Score

    8. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
    9. During the past 4 weeks, how often have you had shortness of breath?*
    10. 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?*
    11. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?*
    12. How would you rate your asthma control during the past 4 weeks?*