BG - Asthma Review Form

BG - Asthma Review Form

This form is used for your Annual Asthma Review. Please answer the questions and submit this form to us.

Your completed questionnaire will be reviewed by me, Nikki Kierans, Specialist Respiratory Nurse, to ensure that the management of your condition is optimised.  The Surgery will contact you if I feel that you need a face-to-face review in the surgery based on your questionnaire. 

If you have any concerns regarding your Asthma at any time, please feel free to contact the surgery.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • General Health Information

    Smoking Status?

  • 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?
    Since your last Asthma review, have you had any asthma exacerbations, oral corticosteriod use or any time off work/school?
    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 (rescue) inhaler (usually blue) or nebuliser medication?
    How would you rate your asthma control during the past 4 weeks?

  • Hospital Admissions

    A Hospital Admission is defined as an overnight stay on a ward.

  • Asthma Review

    Do you have any of these devices at home for your use? (optional)
    How would you describe your inhaler technique? Please go to www.rightbreathe.com and select your inhaler. Follow the guidance for inhaler technique and let us known if you would like some more advice. (optional)
    How would you described your use of Bronchodilators (usually blue)? (optional)
    Do you sometimes forget to take your preventer (usually brown/purple) inhaler? (optional)
    In the last 4 weeks, how often has your Asthma bothered you when you exercise or play? (optional)
    How would you describe your use of inhaled steroids (usually brown/purple)? (optional)

  • Consent

    If the Respiratory Nurse is happy with the current control of your Asthma from this questionnaire, are you happy for your review to take place based on these answers (without contact)?
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA
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Page last reviewed: 10 April 2024
Page created: 09 May 2022