Asthma Review

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

Full Name

Date of Birth

Phone Number

Email Address

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?

 
 
 
 
 

Are you happy for us to postpone your Asthma Annual Review with the Practice Nurse for 12 months? (If your asthma deteriorates within these 12 months, you can see the Nurse anytime)

 
 

The Nurse should inform you of your asthma score via text message within 2 weeks.

If your asthma control is poor you will not be able to postpone your asthma review.