Patient Asthma Review Questionnaire

Dear patient

Thank you for taking the time to complete this asthma review form. The Practice Nurse or Pharmacist will review all completed asthma review forms and will contact you by telephone to complete a short telephone consultation. However, please be aware that you may still be required to attend an appointment for an asthma review if the Practice Nurse or Pharmacist thinks that this is necessary.

Please do not use this form for any other medical queries either routine or urgent.

Complete all questions on this form.

Asthma Review Form

Are you completing this form on behalf of:

What is your relationship to the patient

About you (The patient)

Your first name

Your surname

Your address

Post code

Your date of birth

Sex

Your landline telephone number

Your mobile telephone number

Your email

This questionnaire is to review your asthma, and the practice might not see this report for up to 10 working days. If you are having severe symptoms, please seek urgent assessment by contacting the practice directly or if closed, call the GP out of hour’s service, or attend A&E if a medical emergency.

How often does your asthma cause symptoms during the day?

How often does your asthma cause symptom's at night?

How often does your asthma limit your activities?

How many asthma exacerbations (attacks) requiring an appointment or change of treatment have you had in the past 12 months?

How many times have you had attended Accident and Emergency with asthma symptoms since your last review appointment?

Asthma Control Test Score

The asthma control test provides a score to help healthcare provider determine if your asthma symptoms are well controlled.

If you are 12 years or older, please complete the questions below.

How often in the past 4 weeks did your asthma prevent you from getting as much done at work/school/home?

How often do you have shortness of breath?

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

How often have you used your reliver inhaler? (Usually blue)

How compliant are you with your inhaler or how would you rate your inhaler technique?

How would you rate your asthma control?

If you have a peak flow meter, what was your reading this week?

Height & Weight

Please provide your height and weight for our records if known?

Height in centimetres or feet & inches

Your current weight in kilograms or stones & pounds

Smoking review

Do you currently smoke

Have you smoked in the past?

How many cigarettes do you smoke in a day?

Do you use an E-cigarette?

Are you exposed to cigarette smoke for example at home or work?

If you currently smoke, are you interested in trying to quit or reduce your smoking?

Alcohol comsumption

How often do you have a drink containing alcohol?

How many units of alcohol do you drink in a typical day when you are drinking?

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?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Park Medical • Great James Street Health Centre, Great James Street, Derry, BT48 7DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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