Submit an Asthma Review Form If you have been advised by the surgery to submit an annual review of your asthma symptoms please use the form below. If your symptoms are deterioriating or you are having any concerns please make an appointment with our Nurse. About YouName* First Last Date of Birth* Date Format: DD slash MM slash YYYY Email Section BreakYour Asthma ReviewIn the last month have you had difficulty sleeping due to your asthma (including cough)?YesNoHave you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?YesNoHas your asthma interfered with your usual daily activities (e.g., school, work, housework)?YesNoHow often do you need to use your reliever inhaler?Never1-2 times a month1-2 times a week1-2 times a day2+ times a daySince 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?YesNoPlease give detailsSince your last review, have you needed a course of steroid tablets to get your asthma under control?YesNoDo you smoke?YesNoDid you have a flu vaccination last flu season?YesNoPlease 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?)Please note that the details you give will be used to update your medical records.
