Asthma Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine asthma review.

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.

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 Review

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

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly:

Asthma UK Inhaler Videos

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

Lifestyle - Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical drinking day? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Lifestyle - Smoking

Do you smoke?
Do you use an e-cigarette?
If you smoke, would you like help to quit smoking?

For further information, please see: NHS Quit Smoking information page

Additional Questions

Do you have a written asthma care plan?

Please see the following links for further information on asthma that you may find useful:

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? *