Search

Asthma annual review questionnaire

Please complete the form below:

	Name:

	Address:

	Tel. No:

	Height:

	Weight:

	Do you have an asthma action plan?

	Peak Flow reading(best of three) (If you need a peak flow meter, please contact us.)


	In the last month
	Have you experienced any daytime symptoms such as wheeze, chest tightness or shortness of breath?
	Yes No
	If you answered yes to the above please select the most applicable option:
	Most Days 1-2 times a week 1-2 times a month
	Has your asthma affected your day to day activities such as work, housework or exercise?
	Yes No
	If you answered yes to the above please select the most applicable option:
	Most Days 1-2 times a week 1-2 times a month
	Does your asthma wake you up at night or earlier than usual in the morning?
	Yes No
	If you answered yes to the above please select the most applicable option:
	Most Days 1-2 times a week 1-2 times a month

	If you answered yes to any of the above questions you need to make an appointment for a review as your asthma is not well controlled

	Do you have a reliever inhaler (often blue)
	Yes No
	If Yes, how often do you use it: times a day / week /month or Never(please write out in full)

	If you use your reliever more than 3 times a week you need to make an appointment for a review as your asthma is not well controlled

	Do you smoke?
	Yes No
	If Yes, how many a day:

	Are you an ex-smoker?
	Yes No
	If Yes, when did you quit?

	If you smoke and would like help stopping smoking, our smoking cessation counsellors offer a successful support scheme to assist patients in giving up smoking. If you would like to access this service please pick up a form from reception.

	Anything else you feel we should know about or any other comments?

Site Last Updated 16-Feb-24