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.

Download an Asthma Management Plan (to be completed with your doctor or nurse)

Asthma Review (new)

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.

Phone Number:

Email Address: *

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.

Health Information

Height (ft/inches or metres): *

Weight (st/lbs or kg): *

Peak flow: *

Triggers: *

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? *

All of the time

Most of the time

Some of the time

A little of the time

None of the time

During the past 4 weeks, how often have you had shortness of breath? *

More than once a day

Once a day

3-6 times a week

1-2 times a week

Not at all

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? *

4 or more times a week

2-3 nights a week

Once a week

Once or twice

Not at all

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

3 or more times a day

1-2 times a day

2-3 times a week

Once a week or less

Not at all

How would you rate your asthma control during the past 4 weeks? *

Not controlled

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

Calculated Asthma Score: