Asthma Review Questionnaire

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.

  • 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.

    How often does your asthma cause symptoms during the day?
    How often does your asthma cause symptoms at night?
    How often does you asthma limit your activities?

  • 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: https://www.asthma.org.uk/advice/inhaler-videos/

    I have watched the above relevant inhaler technique videos and am happy with my inhaler technique

  • Your Lifestyle - Smoking

    For further information, please see: www.nhs.uk/smokefree

    Do you smoke?
    Do you use an e-cigarette?
    How many cigarettes did/do you smoke a day?
    Would you like help to quit smoking?

  • 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.

    How often did your asthma prevent you from getting as much as much done at work/ school/ home?
    How often have you had shortness of breath
    How often do your asthma symptoms wake you up at night or early in the morning?
    How often have you used your reliever inhaler (usually blue)?
    How would you rate your asthma control?

  • 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.

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Page last reviewed: 16 November 2020
Page created: 09 November 2020