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

Section

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? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

If your score is 25+:

Well done

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

Next Steps

When you are happy with all your above answers, please select submit below and the questionnaire will be automatically sent to your GP practice. Depending on your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book and appointment if required.