Asthma review questionnaire

Full name*

Your date of birth*

Phone number*

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?*

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 nebulizer medication (such as salbutamol)?*

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

Are you confident that you can use your inhalers correctly?*

Yes
No

Are you sure you know which inhaler is your reliever and which is your preventer inhaler ?*

Yes
No

Do you smoke?*

Yes
No

Have you needed antibiotics or steroids this year due to asthma?*

Yes (If yes, how many times? Please complete the box that appears below after choosing this option)
No

Number of time you have needed antibiotics or steroids this year due to asthma?

Finally if you have a peak flow meter could you take a reading and enter it here

Consent*

I agree to the privacy policy.

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

Asthma Review Questionnaire

Helpful links