Asthma Review

For patients who are due an annual asthma review.

Please would you answer the questions on the form below and submit it to us.

If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well.

Asthma Review

Name
MM slash DD slash YYYY
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 you asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning ?
During the past 4 weeks, often do you need to use your reliever inhaler? *
How would you rate your asthma control during the past 4 weeks? *
Do you have an asthma management plan? *
Are you confident on what you need to do in an emergency
In the last 12 months, have you needed antibiotics or steroids for exacerbation of your asthma? *