Asthma Review Questionnaire

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or a Doctor as well.

Last Updated: 16/11/2020

Asthma Review

Please complete the following questions to allow your health care professional to assess your asthma. This questionnaire is for a routine review of your symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Inhaler Technique

Its is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that needs it. Please watch the specific inhaler video to check that you are using your inhalers correctly. For further information, Please see:

Your Lifestyle - Smoking

For further information, please see:

Asthma Control Test Score

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled. If you are 12 years or older, please complete the following questions.

Further Questions

Your Details

Follow Up:

When you are happy with all your above answers, please submit the form. Depending upon your answers and other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.