Asthma Annual Review

Title

First Name / s

Last Name / s

Date of Birth

Address

Post Code

Home Telephone

Mobile Telephone

When was your asthma diagnosed?

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

If yes, please provide details

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

If yes, please provide details

How often do you use your blue inhaler?

Please provide details of your blue inhaler usage

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Have you ever had your peak flow measured at the surgery?

If yes, do you know your best PEFR value? If yes please provide the reading here.

Are you happy with your inhaler technique?

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

Have you ever smoked?

If yes, do you smoke now?

If yes, how many do you smoke in a day?

If no, when did you quit?

Would you like us to contact you with details of the options available to quit smoking?

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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
Sidings Medical Practice • Sleaford Road Medical Centre, Sleaford Road, Boston, PE21 8EG.

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.

Submit Form

Your Neighbourhood Professionals. Just a Click Away!

Key Information

BBC Health News

Asthma Annual Review

Privacy Protection

Sidings Medical Practice