ASTHMA REVIEW

In the last month, have you had any difficulty sleeping due to your asthma (including cough)?

Yes
No

In the last month, have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day?

Yes
No

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

Yes
No

In the last month, have you regularly needed to use your (blue) reliever inhaler?

Yes
No

In the last year, have you needed to see a doctor as an emergency or attend A&E as a result of your asthma?

Yes
No

In the last year, have you needed a course of steroid tablets to get your asthma under control?

Yes
No

Do you smoke?

Yes
No

Do you have any concerns about your asthma treatment?

Yes
No

Name

Strength

How many puffs?

How many times per day?

Via a space device? Yes/No

Inhaler 1:

Inhaler 2:

Inhaler 3:

Inhaler 4: