Child Asthma Review Form 12 & under

This form is used for your 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 to the respiratory nurse or a Doctor as well.

Your Details

Name of Parent / Guardian *

Name *

Date of Birth *

Phone Number

Email Address *

Asthma Review

How is your Asthma today? *

How much of a problem is your Asthma when you run, exercise or play sports? *

Do you cough because of your Asthma? *

Have you had your Asthma symptoms during the night? *

Parent - During the last 4 week, how many days did your child have any daytime Asthma symptoms *

Parent - How many days did your child wheeze because of asthma? *

Parent - During the last 4 weeks, how many days did your child wake up during the night because of Asthma? *

Have you used your reliever inhaler (usually blue) ?

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? *

Yes No

If 'Yes' please give details

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

Yes No

If 'Yes' please give details

How would you rate your Asthma control *

Do you have an Asthma care plan? *

Yes No

What is your current height / weight

Did you have a flu vaccination last flu season?

Yes No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?)

If you have a peek flow, please privide a reading

The completed form will be reviewed by the Practice Nurse who will contact you if you or she has any concerns *

I consent to the Practice Nurse contacting me if she has any concerns with my Asthma control

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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Child Asthma Review Form 12 & under

Child Asthma Review Form 12 & under

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