Asthma Review - Riversley Road Surgery, Riversley Road, Warwickshire, CV11 5QT

For patients who are due an annual asthma review.

Please would you answer the questions on the form below and submit it to us.

If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well

Asthma Annual Review Questionnaire

Name

First

Last

Date of Birth

Contact Number

Address

City

State/Province

Post Code

1. When was your asthma diagnosed?

2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of symptoms during the day:

4. How often do you use your blue inhaler?

Details of inhaler use:

5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Have you ever had your peak flow measured at the surgery?

If yes, do you know your best PEFR value (ml/min)

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice

8. Have you ever smoked?

If ‘Yes’, please answer the following: Do you smoke now?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

If ‘Yes’ how many do you smoke each day?

If ‘No’ when did you quit? If ‘No’ when did you quit?

If you are human, leave this field blank.