Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Asthma Review

Asthma Review

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.

Phone Number:

Email Address: *

This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Smoking

What is your current smoking status?

Never smoked tobacco

Ex-Smoker

Light Smoker 1-9 per day

Moderate Smoker 10-19 per day

Heavy smoker 20-39 per day

Control

Are there any triggers for your asthma?

Aspirin induced asthma

Airborne dust

Cold air

Damp

Stress

Exercise

Perfume

Pollen

Respiratory infections

None

Other

Please specify:

RCP Questions

How often does your asthma disrupt your sleep?

Most nights

One or two times a week

One or two times a month

Never

Other

Please specify:

How often does your asthma affect you during the day?

Most days

One or two times a week

One or two times a month

Never

Other

Please specify:

How often does your asthma affect your activities?

Most days

One or two times per week

One or two times a month

Never

Other

Please specify:

Other Details

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Hospital Admissions

Have you attended A&E since your last asthma review?

Yes

No

If so, when?

Vaccinations

If you are completing this form survey between September-December, are you happy to receive a flu vaccination, if eligible?

Yes

No

If you are aged 65 or over when completing this form, would you like to receive a pneumococcal vaccination?

Yes

No

If you are aged 70 or 78 when completing this form, would you like to receive a shingles vaccination?

Yes

No

Your answers will now be reviewed by a member of the Hollies Medical Practice team; if there are any concerns over your answers or information missed we will contact you.

*

I certify that I have answered these questions to the best of my knowledge and have not omitted information that may affect my future health

Submit