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 Annual Review Form Asthma Annual Review Questionnaire Asthma Annual Review Questionnaire Contact Details Name Name First First Last Last Date of Birth Contact NUmber Address Address Address Address City City State/Province State/Province Post Code Post Code Email Confirm Email Questionnaire When was your asthma diagnosed? Please SelectLess than 5 years agoMore than 5 years agoMore than 10 years ago In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? Please SelectNoYes, every dayYes, 1- 2 times each weekYes, 1- 2 times each monthYes, 1- 2 times each yearYes, see below for datails Details of sleeping difficulties: In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? Please SelectNoYes, every dayYes, 1- 2 times each weekYes, 1- 2 times each monthYes, 1- 2 times each yearYes, see below for datails Details of symptoms during the day: How often do you use your blue inhaler? Please SelectDailyWeeklyMonthlyAnnuallyOther, See below for details Details of inhaler use: In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? Please SelectYesNo Have you ever had your peak flow measured at the surgery? Please SelectYesNo If yes, do you know your best PEFR value ml/min Are you happy with your inhaler technique? Please SelectYesNo 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? Please SelectYesNo If ‘Yes’, please answer the following: Do you smoke now? Please SelectYesNo 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? Please SelectYesNo If you are human, leave this field blank. Submit 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.