Asthma review questionnaire

Required
Date of birth Required
1. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? Required
2. During the past 4 weeks, how often have you had shortness of breath? Required
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? Required
4. During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication? Required
5. How would you rate your asthma control during the past 4 weeks? Required

An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention (for more information follow this link)

Required

Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery.

8. What is your smoking status? Required
10. Does anyone else in your household smoke? (if patient is 19 years old or younger) Required
Required
Required
Required