Asthma review (adults)

Full Name:

Phone Number:

Smoking

Please select the answer that best describes you: Required

Asthma Triggers and Symptoms

How frequent are your day symptoms? Required

Asthma never causes daytime symptoms

Asthma causes daytime symptoms 1 to 2 times per month

Asthma causes daytime symptoms 1 to 2 times per week

Asthma causes daytime symptoms most days

Asthma cause very frequent daytime symptoms

How frequent are your night symptoms? Required

Asthma never causes night time symptoms

Asthma causes night time symptoms 1 to 2 times per month

Asthma causes night time symptoms 1 to 2 times per week

Asthma causes symptoms most nights

Asthma causes very frequent night time symptoms

How does asthma limit your activities? Required

Asthma does not limit activities

Asthma limits activities 1 to 2 times per month

Asthma limits activities 1 to 2 times per week

Asthma limits activities most days

Asthma very frequently limits activities

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)?

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

Calculated Asthma Score:

Additional 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?

Yes

No

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

Yes

No

Did you have a flu vaccination last flu season?

Yes

No

Did you feel your asthma has been resolved?

Yes

No

Please watch these short video(s) on how to use your inhalers

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) however I would like a further explanation

Confirmation

I confirm that the information provided is accurate to the best of my knowledge and I have been asked to complete this form by a clinician

If you require further treatment and would like to, please make an appointment.

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About You

Smoking

Asthma Triggers and Symptoms

Asthma Control Score

Additional Questions

Please watch these short video(s) on how to use your inhalers

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