Asthma review (adults)

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

In the last month

How often does your asthma cause symptoms at night? Required

Asthma never causes night time symptoms

Asthma causes night time symptoms 1-2 times per month

Asthma causes night time symptoms 1-2 times per week

Asthma causes symptoms most nights

How often does your asthma cause symptoms during the day? Required

Asthma never causes day time symptoms

Asthma causes day time symptoms 1-2 times per month

Asthma causes day time symptoms 1-2 times per week

Asthma causes symptoms most day times

How often does asthma limit your activities? Required

Asthma never limits activities

Asthma limits activities 1-2 times per month

Asthma limits activities 1-2 times per week

Asthma limits activities most days

Asthma control test

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? Required

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

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? Required

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

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

Further 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? Required

Yes

No

Since your last review, have you needed a course of steroid tablets to get your asthma under control? Required

Yes

No

Smoking

Smoking status: Required

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? Required

Yes

No

Ex Smoker

Rollups – How many grams of tobacco did you smoke per week? Required

Pipe – How many grams of tobacco did you smoke per week? Required

When did you give up smoking? Required

Are you currently exposed to second hand smoke at home? Required

Yes

No

Further questions

Did you have a flu vaccination last flu season? Required

Yes

No

Do you have a personalised asthma care plan? Required

Yes

No

Inhalers can help:

relieve symptoms when they occur (reliever inhalers)
stop symptoms developing (preventer inhalers)

Some people need an inhaler that does both (combination inhalers).

Watch a short video from Asthma UK to learn how to use your inhaler properly (opens in new tab)

Please let us know that you have watched and understood the video(s):

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) but I would like more information

Do you have anything you would like to discuss regarding your asthma?

Terms and conditions Required

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

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In the last month

Asthma control test

Further Questions

Smoking

Smoker

Ex Smoker

Further questions