Asthma Questionnaire

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please speak to reception to make an appointment to see the respiratory nurse.

Last Updated: 01/10/2024

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Asthma Control Score

Asthma Review

If you have not already had your flu vaccination this winter do you wish to have one? (Every year between October and December, not needed if you just use a blue rescue inhaler) *

Yes No

Do you smoke? *

Never Smoked

Ex Smoker

Current Smoker

If you answered yes to the above question, please may you advice how many you smoke per day? (Please be advised if you would like help to stop smoking you can call Healthy Lifestyles for support on 01952 382582) *

How many times have you had antibiotics and/or steroids when your chest has been bad in the last 12 months? *

Have you had to use any inhalers for over 12 months?

Yes No

Please confirm if you consent to receiving your personalised asthma care plan electronically. *

Yes No

Do you have a peak flow meter? If not, would you like a prescription for this? *

Consent

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.

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Asthma Questionnaire

Further Information