Asthma Review - Wargrave House Surgery

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 Annual Review Form

Asthma Annual Review Questionnaire

Contact Details

Name

First

Last

Date of Birth

Contact NUmber

Address

City

State/Province

Post Code

Confirm Email

Questionnaire

When was your asthma diagnosed?

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

How often do you use your blue inhaler?

Details of inhaler use:

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Have you ever had your peak flow measured at the surgery?

If yes, do you know your best PEFR value

ml/min

Are you happy with your inhaler technique?

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

Have you ever smoked?

If ‘Yes’, please answer the following:

Do you smoke now?

If ‘Yes’ how many do you smoke each day?

If ‘No’ when did you quit? If ‘No’ when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

If you are human, leave this field blank.

Asthma Info

www.Asthma.com – this gives the link to the Asthma Control test. If more than 12 years of age use the adult one if less than 12 years its the childhood asthma control test

www.rightbreathe.com – This is good for inhaler information and demonstrations of how to use

www.asthma.org.uk – Brilliant for creating own care plans and all information on Asthma

www.nhs.uk/conditions/asthma

Inhaler Technique – An interactive QR code based poster to help improve inhaler technique.