Asthma Review Form If you have been invited by the practice to submit an asthma review, please complete this form. Asthma Review First Name * Last Name * Date of birth * Please use format day/month/year e.g. 12/05/1979 If you are completing this from on behalf of someone else please state your name and relationship to the patient For example, a parent of a child aged 12-15. Email * Phone Number * * I confirm that I have no new concerns about my asthma or asthma medications (if you have new concerns/questions please book an appointment to discuss further) Your Asthma Review When was your asthma diagnosed? * Less than 5 years agoMore than 5 years agoMore than 10 years ago Has your medication changed since last year? * Yes No I am happy with my inhaler technique * Yes No 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. I have a spacer device * Yes No, but I would like more information about this No and I do not want one Please list the inhalers and medication you regularly use for your asthma * Please answer the following questions about your overall asthma control, thinking about your control over the past month. Have you had difficulty sleeping because of your asthma control - including nocturnal cough? * Yes No Have you had asthma symptoms during the day? * Yes No Has your asthma interfered with your usual daily activities (school/work/housework etc)? * Yes No How often have you needed to use your reliever (blue) inhaler? * 1-2 times a month1-2 times a week3 or more times a week2+ times a day Since your last review, have you needed to see a doctor as an emergency relating to your asthma? * Yes No 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? * Yes No Do You Smoke? Never smoked Ex smoker Light Smoker 1-9/day Moderate smoker 10-19/day Heavy smoker 20-39/day Very heavy smoker 40+/day Smoking cessation Yes - I would like help to stop smoking No thanks - not right now N/A I don't smoke 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 Yes Please - I would like to have a 'flu vaccination No thanks - I do not want a 'flu vaccination this year I have already had my 'flu vaccination this year at the surgery I have already had my 'flu vaccination elsewhere (via employer/chemist etc) 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/ Check and Send
