The Chaucer Surgery

Part of the Spirit Primary Care Group

Asthma Review Form

If you have been invited by the practice to submit an asthma review, please complete this form.
Asthma Review
Please use format day/month/year e.g. 12/05/1979
For example, a parent of a child aged 12-15.
*

Your Asthma Review

Further information can be found on the Asthma UK website here: https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers or you can discuss this with your pharmacist.

Please answer the following questions about your overall asthma control, thinking about your control over the past month.

Has your asthma interfered with your usual daily activities (school/work/housework etc)? *
Since your last review, have you needed to see a doctor as an emergency relating to your asthma? *
This includes attending the walk-in centre, GP Out of Hours or A+E.
Have you been prescribed oral steroids (prednisolone) in the past 2 years? *
Do You Smoke?
Smoking cessation
If you smoke, giving up smoking is the single best thing you can do for your health. We can offer you support to cut down and quit. Please indicate if you would like us to contact you regarding support to stop smoking.
Seasonal 'Flu vaccination
As an asthmatic, you are entitled to a yearly seasonal flu jab at the medical centre. Flu vaccinations are offered at the practice each Autumn. For further information about the vaccinations, see the NHS website: https://www.nhs.uk/conditions/vaccinations/flu-influenza-vaccine/

The Chaucer Surgery
Off School Walk
Attleborough
Nuneaton
Warwickshire
CV11 4UZ

Tel: 024 7638 3784
Email: [email protected]

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