Asthma Review

For patients who are due an annual asthma review.

Please would you answer the questions on the form below and submit it to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well.

Fields marked with an asterisk (*) are compulsory.

Asthma Annual Review Questionnaire

  • Your details:

  • Questionnaire:

  • Details of sleeping difficulties:
  • Details of symptoms during the day:
  • Details of inhaler use:
  • If yes, do you know your best PEFR value
  • If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.
  • If 'Yes', please answer the following:
  • Do you smoke now?
  • If 'Yes' how many do you smoke each day?
  • If 'No' when did you quit?

Note:
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.