Review Asthma Form - Tangmere Medical Centre

Have you had shortness of breath? *

Does your asthma prevent you from getting as much done at work/school/home/exercise? *

Does you Asthma affect your activities *

Do your asthma symptoms wake you up at night or early in the morning? *

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *

Have you had your Asthma symptoms during the night? *

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 *

Please privide a recent peak flow reading. (If you are able to)

Do you have a recent asthma care plan *

Yes No

What is your current Height and Weight

Do you smoke?

Yes No

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?)

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.

Asthma Review Form

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Asthma Review Form

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