Asthma review

This form is for patients with asthma who feel their symptoms are well controlled. If you are having repeated attacks of a tight chest, please contact our practice nurse for a face-to-face review.

About your asthma
Have you had any difficulty sleeping because of your asthma symptoms (including cough)? *Required
Have you had any of your usual asthma symptoms during the day (coughing, wheezing, chest tightness or breathlessness)? *Required
Does your asthma interfere with your usual activities (e.g. housework, work, school etc.)? *Required
How often do you need to use your reliever (ventolin/blue) spray? *Required
Do you feel you can use your inhaler correctly? *Required
Do you wake in the night or early morning because of a cough? *Required
Have you had any oral steroids (prednisolone) this year for an asthma exacerbation? *Required
Have you taken antibiotics this year for a chest infection? *Required
Have you been admitted to hospital in the past year or two because of your asthma? *Required
Smoking/tobacco use

Please provide the following information in relation to smoking (please tick all that apply):

Passive smoking
Are you exposed to smoke at work? *Required
Are you exposed to smoke at home? *Required
Do you know your peak flow reading? *Required

What happens next?

Your form will be passed to the practice nurse to review. If they feel that a further detailed review is needed you will be contacted to arrange an appointment. Medication will be issued if there are no concerns.

gtd healthcare often uses text messages to let you know about appointments, test results or when prescriptions are ready. Are you OK for us to send you texts? *Required
Please tick the following if you agree: *Required

Further information

Please follow the link below to view video links on how best to use your inhaler: https://www.asthma.org.uk/advice/inhaler-videos/