Asthma Review

During busier periods we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible.

If you have recently changed your contact details, please let us know.

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.

All used inhalers should be returned to your nearest pharmacy for them to dispose of safely. Inhalers are thermally treated to destroy the greenhouse gases. Inhalers should not be thrown away in household waste. Please see a list of Participating Pharmacies.

Asthma Review

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.

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 - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

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

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

If you are needing to use your reliever (usually blue) inhaler more than 2-3 times a week then your asthma may not be well controlled. If so, please also make an appointment to discuss your inhalers with one of our asthma nurses.

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

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5