Asthma Review

Due to the current crisis we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

Is this the right review form for you? Please note that there are separate forms for Asthma, COPD, the contraceptive Pill and medication reviews. Please ensure that you complete the correct form.

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.

Recycle your inhalers.

Asthma Review

Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
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? *
During the past 4 weeks, how often have you had shortness of breath? *
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? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

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? *