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 by emailing bnssg.cedarssuregry@nhs.net. 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.

Title

Home address

First Name

Town / City

Last Name

Region

Date of Birth

Postcode

Home Telephone

Mobile Telephone

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:

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

Yes No

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

Yes No

If yes, do you know your best PEFR value (ml/min)

Are you happy with your inhaler technique?

Yes No

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?

Yes No

If 'Yes', please answer the following:

Do you smoke now?

Yes No

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?

Yes No

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

During the past 4 weeks, how often have you had shortness of breath?

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?

How would you rate your asthma control during the past 4 weeks?

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
compulsory.

Note:
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

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Improved Access

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.

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Location: 87 New Bristol Road, Weston-super-Mare, BS22 6AJ

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