Adult 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.

Adult Asthma Review

Adult Asthma Review

Section

In the last month...

How often does your asthma cause symptoms at night? *
How often does your asthma cause symptoms during the day? *
How often does asthma limit your activities? *

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms a clinician may be able to help you, please them know.

If your score is 25+:

Well done

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing symptoms a clinician may be able to help you, please add these into the comments box at the end of this form.

Additional Questions

Please complete the additional questions below and then submit your review.

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? *

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

Are you currently exposed to second hand smoke at home? *
Did you have a flu vaccination last flu season? *
Do you have a personalised asthma care plan? *
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): *
*