Asthma review

Name

Date of birth

Home number/ Mobile number

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

1) All of the time

2) Most of the time

3) Some of the time

4) A little of the time

5) None of the time

During the past 4 weeks, how often have you had shortness of breath?

1) More than once a day

2) Once a day

3) 3-6 times a week

4) 1-2 times a week

5) Not at all

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?

1) 4 or more times a week

2) 2-3 nights a week

3) Once a week

4) Once or twice

5) Not at all

During the past 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as salbutamol)?

1) 3 times or more per day

2) 1 or 2 times per day

3) 2 or 3 times per week

4) Once a week or less

5) Not at all

How would you rate your asthma control during the past 4 weeks?

1) Not controlled

2) Poorly controlled

3) Somewhat controlled

4) Well controlled

5) Completely Controlled

Does your asthma affect you on a daily basis?

Yes

Does you asthma limit your daily activities

Yes

Does your asthma disturb your sleep?

Yes

How many exacerbations/flare-ups of asthma have you had in the last 12 months? Please enter a number.

How many times have you been admitted to hospital in the last 12 months with an exacerbation of asthma? Please enter a number.

Would you like to receive a copy of your Asthma Management Plan in the post following your review?

Yes

Height (inches/cm)

Weight (stone/kg)

Blood Pressure reading if you have access to a blood pressure machine

Peak flow reading if you have access to a peak flow device

Smoking statusDo you smoke (cigarettes, cigars and vaping). If yes, then how many a day. If you quit, tell us how many you used to smoke and when you quit.

Alcohol units per week

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