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.

Please only complete this form if asked to by a clinician.

Asthma Review

Asthma Review

If you are human, leave this field blank.

Registered practice: *

Please select... Horizon Healthcare St Thomas Road Surgery

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 Review

Please select the answer that best describes you: *

I am a smoker

I am an ex smoker

I have never smoked

I am an e-cigarette user

I am an ex e-cigarette user

At what age did you start smoking? *

Number of years you have smoked for: *

How many cigarettes do you smoke a day? *

1-9

10-19

20-39

40+

If you smoke loose tobacco, how many grams a day do you smoke?

How many cigarettes did you smoke a day? *

1-9

10-19

20-39

40+

Asthma Triggers and Symptoms

Please select all answers that trigger your Asthma:

Cold Air

Warm Air

Damp

Humidity

Wind

Dust Mites

Airborne Dust

Pollen

Emotions

Exercise

Perfume

Respiratory Infection

Seasonal

Tobacco Smoke

Work Related

Animals

Unsure

Other

Please specify trigger: *

What are your normal symptoms?

Tight Chest

Shortness of Breath

Asymptomatic

Wheezing

Coughing

Other

Please specify:

How frequent are your day symptoms? *

Asthma never causes daytime symptoms

Asthma causes daytime symptoms 1 to 2 times per month

Asthma causes daytime symptoms 1 to 2 times per week

Asthma causes daytime symptoms most days

Asthma cause very frequent daytime symptoms

How frequent are your night symptoms? *

Asthma never causes night time symptoms

Asthma causes night time symptoms 1 to 2 times per month

Asthma causes night time symptoms 1 to 2 times per week

Asthma causes symptoms most nights

Asthma causes very frequent night time symptoms

How does asthma limit your activities? *

Asthma does not limit activities

Asthma limits activities 1 to 2 times per month

Asthma limits activities 1 to 2 times per week

Asthma limits activities most days

Asthma very frequently limits activities

Additional Questions

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes

No

Please give details:

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes

No

Did you have a flu vaccination last flu season?

Yes

No

Did you feel your asthma has been resolved?

Yes

No

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

*

I confirm that the information provided is accurate to the best of my knowledge and I have been asked to complete this form by a clinician

If you require further treatment and would like to, please make an appointment.

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