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Water Meadow Surgery

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Water Meadow Surgery, 31a Red Lion Street, 01494 782241

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Asthma Review

If you are due your annual asthma review please use this form.

If your asthma symptoms have changed or if you have any questions or concerns, please make an appointment with the respiratory nurse or doctor.

Last Updated: 17/08/2023

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Asthma Control Test

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

All of the time (1)

Most of the time (2)

Some of the time (3)

A little of the time (4)

None of the time (5)

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

More than once a day (1)

Once a day (2)

3-6 times a week (3)

1-2 times a week (4)

Not at all (5)

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? *

4 or more times a week (1)

2-3 nights a week (2)

Once a week (3)

Once or twice (4)

Not at all (5)

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

3 or more times a day (1)

1-2 times a day (2)

2-3 times a week (3)

Once a week or less (4)

Not at all (5)

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

Not controlled (1)

Poorly controlled (2)

Somewhat controlled (3)

Well controlled (4)

Completely controlled (5)

Your total score *

Review Questionnaire

Please list the inhalers you use on a regular basis (name/strength/how many puffs/how many times a day/if via a spacer)

Please list the inhalers you use on a regular basis (name/strength/how many puffs/how many times a day/if via a spacer)

In the last month, have you had difficulty sleeping due to your asthma (including cough)?

Yes No

In the last month, have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes No

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

Yes No

How often do you need to use your reliever (blue) inhaler?

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes No

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes No

Do you smoke?

Yes No

Did you have a flu vaccination last flu season?

Yes No

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Further Information

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