Asthma Review Form Asthma Review First Name * Last Name * Email * Enter Email Confirm Email * Confirm Email Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Asthma Review When was your asthma diagnosed? * Less than 5 years agoMore than 5 years agoMore than 10 years ago In the last month have you had difficulty sleeping due to your asthma (including cough)? * Yes No Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? * Yes No Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? * Yes No How often do you need to use your reliever inhaler? * Never 1-2 times a month 1-2 times a week 1-2 times a day 2+ times a day 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 provide details: * Have you been prescribed oral steroids to control your asthma since your last review? * Yes No Do you smoke? * Yes Never smoked Ex-smoker Please list the inhalers you use: Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form. Send
