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
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:
Inhaler 2:
Inhaler 3:
Inhaler 4:
If you answered Yes to any of the questions, please arrange an asthma review with one of our Practice Nurses as soon as possible