For patients who are due an annual asthma review.
Please would you answer the questions on the form below and submit it to us by emailing firstname.lastname@example.org. You can do this by accessing the link below (Asthma Control Test), saving it when prompted and then viewing the result and this should allow you to email it to us. Please ensure you indicate which patient the result is referring to if you are emailing on behalf of someone else. Alternatively please print your results and hand them in at reception or by posting to the surgery, again ensuring your name and date of birth are on the hard copy form.
If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or a doctor as well.
About this form
You are due an annual asthma review. Please answer the questions and submit this form 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.
Fields marked with a red asterisk are
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
We are working together with other local practices to offer patients access to more appointments in the early mornings, evenings and at weekends. To find out more about these services, please contact the practice.