Asthma Annual Review Form | Duke Street Surgery

Name

Date of Birth

Address

Postcode

Home Phone

Mobile Phone

Email Address

When was your asthma diagnosed?

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough, wheeze, chest tightness or breathlessness)?

Details of sleeping difficulties

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day

How often do you use your blue inhaler?

Details of inhaler use

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Details of how your asthma has interfered with your usual activities

Have you noticed you have a blocked or runny nose even when you don't have a cold?

Yes

How often do you use your preventer inhaler? (Your preventer inhaler is usually a brown colour. You might also take a preventer medicine using a combined preventer and reliever inhaler.)

Every Day

More than 5 days a week

Occasionally or not at all

Don't have preventer inhaler

1. Have you visited hospital (A&E) for emergency treatment because of asthma in the past two years?

When you haven't had any symptoms in a while, do you…

How do you feel about taking your asthma medication?

Have you ever had your peak flow measured at the surgery?

Yes

Are you happy with your inhaler technique?

Yes

No ( If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice respiratory nurse for more advice.)

Have you ever smoked?

Yes

If you do smoke how many grams per week? Or how many cigarettes per day do you smoke?

If yes, please circle your smoking status:-

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Yes