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 with the respiratory nurse or a doctor as well.

Asthma Annual Review Questionnaire

Contact Details

Address *
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1. When was your asthma diagnosed?
2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?
3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?
4. How often do you use your blue inhaler?
5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?
6. Have you ever had your peak flow measured at the surgery?
7. Are you happy with your inhaler technique?
8. Have you ever smoked?
If ‘Yes’, please answer the following: Do you smoke now?
There are plenty of options available to help you quit. Is this something you would like us to contact you about?