Asthma Review Form Asthma Review First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Asthma Review When was your asthma diagnosed? * Less than 5 years ago More than 5 years ago More than 10 years ago In the last month have you had difficulty sleeping due to your asthma (including cough)? * Yes No Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? * Yes No Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? * Yes No How often do you need to use your reliever inhaler? * Never 1-2 times a month 1-2 times a week 1-2 times a day 2+ times a day 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 Please provide details: * Have you been prescribed oral steroids to control your asthma since your last review? * Yes No Do you smoke? * Yes Never smoked Ex-smoker Please list the inhalers you use: Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Personal information is not stored on this system but may be used to update your records with the practice. Send If you are human, leave this field blank.