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

About You

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

Control

Are there any triggers for your asthma?

RCP Questions

How often does your asthma disrupt your sleep?
How often does your asthma affect you during the day?
How often does your asthma affect your activities?

Other Details

Please select the types of inhalers that you use:

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): *

Hospital Admissions

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

Vaccinations

If you are completing this form survey between September-December, are you happy to receive a flu vaccination, if eligible?
If you are aged 65 or over when completing this form, would you like to receive a pneumococcal vaccination?
If you are aged 70 or 78 when completing this form, would you like to receive a shingles vaccination?

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.

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