Asthma Review

Full name*

Your date of birth*

In the last month/week, have you had difficulty sleeping due to your asthma (including cough symptoms)?*

Have you had your usual asthma symptoms (eg cough, wheeze, chest tightness, shortness of breath) during the day?*

Has your asthma interfered with your usual daily activities (eg school, work, housework)?*

How often do you need to use your reliever inhaler?*

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?*

Since your last review, have you needed a course of steroid tablets to get your asthma under control?*

Do you smoke?*

If yes. Please be aware smoking can affect your health and if you would like to access support for stopping smoking please contact https://www.nhs.uk/oneyou/for-your-body/quit-smoking/ or 01522 705162.

Did you have a flu vaccination last flu season?*

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?)

Consent*

Please note that the details you give will be used to update your medical records.

I agree to the privacy policy.

*

I confirm that the information provided is accurate to the best of my knowledge.

Merton Lodge Surgery