Asthma Annual Review Questionnaire

We offer all of our Asthma patients an annual review. It may not be necessary for you to attend the surgery for this review. Please answer the questions on the form below and return it to the Practice.

If your symptoms are deteriorating or you have any concerns, please make an appointment with the Respiratory Nurse.

Please select the practice location most relevant to this Online Form submission:

Name

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Home Telephone

Mobile Telephone

E-mail address

YOUR ASTHMA

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?

How many asthma exacerbation's (attacks) have you had in the last 12 months?

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 by following the link below to check that you are using your inhalers correctly:

For further information, see: www.asthma.org.uk/advice/inhaler-videos

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

YOUR LIFESTYLE - SMOKING

Do you smoke?

Do you use an E-Cigarette?

Would you like help to quit smoking?

If you are a current smoker how many do you smoke a day?

For further information, please see: https://www.nhs.uk/smokefree

ASTHMA CONTROL TEST SCORE(TO BE COMPLETED IF AGE 12 YEARS AND ABOVE)

How often in the last 4 weeks did your asthma prevent you from getting as much done at work/school/home?

Do you have shortness of breath?

Do your asthma symptoms wake you up at night or early morning?

Do you use your reliever Inhaler (usually blue)?

How would you rate your asthma control?

FURTHER QUESTIONS

I have the following information, questions or concerns that I would like to raise with my Asthma Nurse or Doctor:

THE NEXT STEP - Your completed Asthma Questionnaire will now be reviewed by a Health Care Professional, and we will be in touch again once this has taken place. Should we need to review your treatment &/or control we will be in contact to arrange a face-2-face in our Asthma Clinic or telephone appointment, as appropriate.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Riverside Surgery • Le Molay-Littry Way, Bovey Tracey, Devon, TQ13 9QP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.