Asthma Review

If you have been advised by the surgery that you need an annual review of your asthma symptoms you can submit your review using this form. Please note that ideally you should be seen in surgery at least every 3 years by the asthma nurse. However, if your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Swallowfield Asthma Review

Swallowfield Asthma Review

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.

Do you smoke? *

Yes

No

Did you have a flu vaccination last flu season? *

Yes

No

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 -1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

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

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

Not at all - 5

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 times a week

Once a week

Once or twice a month

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