Sidings Medical Practice

Asthma Annual Review

1Asthma Annual Review

Title

First Name / s

Last Name / s

Date of Birth

Address

Post Code

Home Telephone

Mobile Telephone

Email

When was your asthma diagnosed?Please Choose...Less than 5 years agoMore than 5 years agoMore than 10 years ago

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

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)?Please Choose...YesNo

If yes, please provide details

How often do you use your blue inhaler?Please Choose...DailyWeeklyMonthlyAnnuallyOther

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)?Please Choose...YesNo

Have you ever had your peak flow measured at the surgery?Please Choose...YesNo

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

Are you happy with your inhaler technique?Please Choose...YesNo

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?Please Choose...YesNo

If yes, do you smoke now?Please Choose...YesNo

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?Please Choose...YesNo

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