Asthma Annual 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.

This service is for:

  • Routine clinical reviews
  • Problems that are not life threatening or serious
  • For things where you would expect to wait for a routine appointment

Do not use this service for

  • Things that are urgent and need immediate attention
  • Where you expect a response during out of hours or over a weekend
  • Where your illness is serious – e.g. an asthma attack or hypo
Asthma Annual Review

Asthma Annual 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.

You should allocate 20 minutes to complete this, as you would if you were attending the surgery. Just because a review is conducted remotely, it does not mean it is any less important. If you are to control your asthma well it is vitally important to answer questions honestly and read the information provided.

You have been sent this review because you're taking inhalers and we think you have asthma. Are you taking your inhalers for asthma?

Asthma Control

Asthma control is really important for your clinicians to understand so that they can help to keep you as free from symptoms as possible. Please answer all questions honestly and be as elaborate as possible.

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?

Is your asthma worse when you're at work?

Inhaler Technique

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): *

Exacerbations

Have you had to take any courses of oral steroids in the last year?
Have you had any admissions to hospital or visits to A&E because of your asthma?

Lifestyle

Now we're turning to other lifestyle factors that can have a big impact on your asthma, such as smoking and weight. We recognise these are both sensitive areas for many patients, but if we're to care for you as well as possible and reduce your chances of becoming unwell with your asthma, it's really important that we have an accurate idea of how you're doing in these areas.

What is your current smoking status?

The following information is a stop smoking service available for patients aged over 40 years in Tamworth, for if you wish to stop.

Stopping smoking is the single most effective way to improve your health and prolong your life. We invite you to join our Stop Smoking Programme delivered by Everyone Health for people age 40 and over.

Please call 03330 050 095 or text the word QUIT to 60777 to book your place.

Vaccinations

Have you had your flu vaccination in the most recent flu season?

End of Review

Thank you for completing this online asthma review, do you have any questions or concerns?
*