Asthma Review Form

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

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 week, how often have you had shortness of breath? *

More than once a day

Once a day

3 to 6 times a week

Once a week

Not at all

During the past 4 weeks, how often did you asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wakr you up at night or earlier than usual in the morning? *

4 or more nights a week

2 to 3 nights a week

Once a week

Once or twice

Not at all

How often do you need to use your reliever inhaler?

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

During thr past 4weeks, how often have you used your rescue inhaler or nebulizer medication (such a salbutamol)? *

3 or more times per day

1 or 2 times per day

2 or 3 times per week

Once a week

Not at all

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

Not controlled at all

Poorly controlled

Somewhat

Well controlled

Completely

How ofter do you use your blue inhaler? *

How often do you use your preventer? *

Do you have an action plan? *

Yes No

Are you up to date with your vaccinations? *

Yes No

Do you smoke? *

Yes No

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

Cookies on the St Davids Clinic website

Further Information