Asthma review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Your asthma review

In the last month have you had difficulty sleeping due to your asthma (including cough)?
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? Yes No
Has your asthma interfered with your usual daily activities (e.g., 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?
Did you have a flu vaccination last flu season?
Please note that the details you give will be used to update your medical records.