Emergency messages
Call us on
0117 969 5391
Horfield Health Centre,
Lockleaze Road,
Bristol, BS7 9RR
Menu
Home
Services
Book an Appointment
Prescription Services
Information
Useful Documents
Meet the Team
News
Contact
Alcohol Consumption Review
Asthma Review
Home Blood Pressure Reading
COPD Assessment Test (CAT)
follow us on
ASTHMA REVIEW
Full name
*
Phone number
*
Date of birth
*
E-mail
*
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
Please list the inhalers you use daily or on a regular basis
Name
Strength
How many puffs?
How many times per day?
Via a space device? Yes/No
Inhaler 1:
Name
Strength
How many puffs?
How many times per day?
Via a space device? Yes/No
Inhaler 2:
Name
Strength
How many puffs?
How many times per day?
Via a space device? Yes/No
Inhaler 3:
Name
Strength
How many puffs?
How many times per day?
Via a space device? Yes/No
Inhaler 4:
Name
Strength
How many puffs?
How many times per day?
Via a space device? Yes/No
If you answered Yes to any of the questions, please arrange an asthma review with one of our Practice Nurses as soon as possible