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Asthma review (adults)

Asthma Review
Required fields are labelled
Please be aware that Peak Flow readings are required as part of this form.
Have you received a letter, text message or verbal invitation to complete this assessment? Required
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

Questions about inhalers

For each inhaler, 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 had any asthma exacerbations this year for which you have been prescribed steroid tablets (prednisolone) 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?

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? Required
During the past 4 weeks, how often have you had shortness of breath? Required
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? Required
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? Required
How would you rate your asthma control during the past 4 weeks? Required

Additional Questions

Please complete the additional questions below and then press submit to send your review to your Doctor.

Smoking and Vaping

Smoking/Vaping Status:

Blood Pressure Reading

Further Questions

Are you able to exercise?

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:
Terms and conditions Required