Asthma Review Form - Kings House Surgery

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *

All of the time (Score 1)

Most of the time (Score 2)

Some of the time (Score 3)

A little of the time (Score 4)

None of the time (Score 5)

During the past 4 weeks, how often have you had shortness of breath?

2+ times a day (Score 1)

Once a day (Score 2)

3-6 times a week (Score 3)

1-2 times a week (Score 4)

Not at all (Score 5)

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you at night or earlier than usual?

4+ times/week - Score 1

2-3 Nights/Week - Score 2

Once a week - Score 3

Once or twice - Score 4

Not at all - Score 5

How often do you need to use your reliever inhaler?

3+ times/day - Score 1

1-2 times/day - Score 2

2-3 times/week - Score 3

Once a week or less - Score 4

Not at all - Score 5

How would you rate your Asthma control during the past 4 weeks?

Not controlled - Score 1

Poorly controlled - Score 2

Somewhat controlled - Score 3

Well controlled - Score 4

 Totally controlled - Score 5

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes No

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?)

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.

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