COPD and Asthma Review

If you have been advised by the surgery to submit a COPD and Asthma review, please use this form.

COPD and Asthma Review

Section

Have you received a letter, text message or verbal invitation to complete this assessment?

For each inhaler you use, please tell us how many times each day you use the inhaler and how many puffs of the inhaler you use?

Do you use a spacer when using your inhalers? *

For information on how to use your inhaler, please visit www.asthma.org.uk/advice/inhaler-videos

Have you ever attended an exercise course to improve your breathing?
Have you had any COPD exacerbations this year for which you have been prescribed steroid tablets (prednisolone) or antibiotics for your chest? *
Have you had any overnight hospital admissions relating to your lungs in the past 12 months? *
Do you cough up phlegm/sputum? *
Has this changed since your last review?
How often?
Is this new for you in the past 12 months?

We would like to know about your level of breathlessness, please select the most appropriate comment: *
Has this changed since your last review? *

Are you able to exercise? *
Has this changed since your last review?

Asthma Questions

Have you had any asthma exacerbations this year for which you have been prescribed steroid tablets (prednisolone) for your chest?

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
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? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

If your score is 25:

Well done

Your asthma appears to have been under control over the last 4 weeks.

If you do not have access to a peak flow meter at home, please contact the practice either by phone or by using our Prescription Question form and a peak flow will be provided.

If you would like to know the correct way to use your peak flow meter, please watch this video:

Please be aware that your inhaler may be a different colour to that of the images below.

Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

Has your appetite changed in the past 12 months? *
Do you find it difficult to eat due to shortness of breath?
Do you feel this is related to your COPD?
Has this changed since your last review?

Blood Pressure (if possible)

Smoking and Vaping

Smoking/Vaping Status: *
Would you like to give up smoking/vaping? *

Please visit NHS: Find Your Local Stop Smoking Service (LSSS) - Better Health for further information

Additional Information

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