Asthma Review Questionnaire

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Your Information

Asthma Review

How often does your asthma cause symptoms during the day?: *

How often does your asthma cause you symptoms at night?: *

How often does your asthma limit your activities: *

What triggers your asthma?:

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly:

Asthma UK Inhaler Videos: https://www.asthma.org.uk/advice/inhaler-videos/

I have watched the above relevant inhaler technique videos and am happy with my inhaler technique: *

Lifestyle - Alcohol

How often do you have a drink containing alcohol?: *

How many units of alcohol do you drink on a typical day drinking?: *

For more information please see: https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?: *

Lifestyle - Smoking

Do you smoke?: *

Do you use an e-cigarette?: *

If you smoke, would you like help to quit smoking? (For further information, please see: www.nhs.uk/smokefree): *

Asthma Control Test Score

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled.
If you are 12 years or older, please complete the questions below.

How often did your asthma prevent you from getting as much done at work/school/home?: *

How often have you had shortness of breath?: *

How often did your asthma symptoms wake you up at night or early in the morning?: *

How often have you used your reliever inhaler (usually blue): *

How would you rate your asthma control?: *

Further Questions

Do you have a written asthma care plan?: *

Please see the following links for further information on asthma that you may find useful:

NHS - http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx

Patient.Info - http://patient.info/health/asthma-leaflet

Asthma UK - https://www.asthma.org.uk

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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LIME TREE SURGERY FINDON

Lime Tree Avenue
Findon Valley
Worthing
BN14 0DL

Tel: 01903 264101

Out-Of-Hours Tel: 111

Opening Hours:

Monday 08:00-18:00

Tuesday 08:00-18:00

Wednesday 08:00-18:00

Thursday 08:00-18:00

Friday 08:00-18:00

Saturday CLOSED

Sunday CLOSED

LIME TREE SURGERY DURRINGTON

Durrington Health Centre
Durrington Lane
Worthing
BN13 2RX

Tel: 01903 264101

Out-Of-Hours Tel: 111

Opening Hours:

Monday 08:00-18:00

Tuesday 08:00-18:00

Wednesday 08:00-18:00

Thursday 08:00-18:00

Friday 08:00-18:00

Saturday CLOSED

Sunday CLOSED

LIME TREE SURGERY GORING

Phoenix Medical Centre
4 The Waterfront
Goring-By-Sea
BN12 4FD

Tel: 01903 264101

Out-Of-Hours Tel: 111

Opening Hours:

Monday 08:00-18:00

Tuesday 08:00-18:00

Wednesday 08:00-18:00

Thursday 08:00-18:00

Friday 08:00-18:00

Saturday CLOSED

Sunday CLOSED

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Asthma Review Questionnaire

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LIME TREE SURGERY FINDON

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LIME TREE SURGERY DURRINGTON

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