Asthma review (adults)

About You

First Name:

Surname:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Height:

In cm.

Weight:

In kg.

Smoking Status

Does someone you live with smoke?

Yes

No

Your smoking status:

Never smoked

Ex-smoker

Current smoker

How many cigarettes a day:

Asthma Control Questions

I only use a blue inhaler:

Yes

No

What colour preventer do you use:

Eg. Brown/red/white

How many puffs per day:

How many times per day:

I have taken steroid tablets (prednisolone) for my asthma in the last year:

Yes

No

I have used a nebuliser for my asthma in the last year:

Yes

No

A nebuliser is an electric machine that creates a mist of medicine you breathe in.

I have seen someone other than Brookside, or my pharmacy, for my asthma in the last year:

Yes

No

Please explain who else you have seen for your asthma:

I am confident I know how to use my inhaler:

Yes

No

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?

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 inhaler?

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

Total score:

Out of 25.

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About You

Smoking Status

Asthma Control Questions

Asthma Control Test