Asthma Review

If you suffer from Asthma, you can check how well your asthma is under control by completing this Questionnaire. Once completed one of our Nurses will review your answers.

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Your Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?: *

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?: *

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?: *

How often do you need to use your reliever inhaler?: *

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?: *

Have you been prescribed oral steroids to control your asthma since your last review?: *

Do you smoke?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Asthma Review

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