Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

In the last month have you had difficulty sleeping due to your asthma (including cough)? *
In the last month, have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *
In the last month, has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *
Please choose the appropriate statement: *
How often do you use your rescue inhaler? *

Please note that if you have requested three or more rescue inhalers in the previous 12 months, you will require a face to face review with an Asthma Nurse. A member of the practice will contact you by email or phone, to arrange this.

Peak Flow Meter

Do you have a peak flow meter at home? *