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Asthma review (adults)

Adult Asthma Review
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

In the last month…

How often does your asthma cause symptoms at night? Required
How often does your asthma cause symptoms during the day? Required
How often does asthma limit your activities? Required

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? Required
During the past 4 weeks, how often have you had shortness of breath? Required
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? Required
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? Required
How would you rate your asthma control during the past 4 weeks? Required

Since Your Last Review

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? Required
Since your last review, have you needed a course of steroid tablets to get your asthma under control? Required

Smoking

Smoking status: Required

Further questions

Did you have a flu vaccination last flu season? Required
Do you have a personalised asthma care plan? Required
Please select the types of inhalers that you use:
Confirmation Required