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

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 Review

Please select the answer that best describes you: *
How many cigarettes do you smoke a day? *
How many cigarettes did you smoke a day? *

Asthma Triggers and Symptoms

Please select all answers that trigger your Asthma:
What are your normal symptoms?
How frequent are your day symptoms? *
How frequent are your night symptoms? *
How does asthma limit your 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?
Since your last review, have you needed a course of steroid tablets to get your asthma under control?
Did you have a flu vaccination last flu season?
Did you feel your asthma has been resolved?
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): *
*

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