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Asthma Review

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.

Contact Details



Home Phone*

Mobile Phone*





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 sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

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

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

If yes, do you know your best PEFR value

6. Are you happy with your inhaler technique?  

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.

7. Have you ever smoked? 

If 'Yes', please answer the following:

Do you smoke now?

If 'Yes' how many do you smoke each day?

If 'No' when did you quit? 

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

Asthma control score

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

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

10. 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?*

11. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?*

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

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