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Asthma review (adults)

Asthma Review
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you
In cm.
In kg.

Smoking Status

Does someone you live with smoke?
Your smoking status:

Asthma Control Questions

I only use a blue inhaler:
I have taken steroid tablets (prednisolone) for my asthma in the last year:
I have used a nebuliser for my asthma in the last year:
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:
I am confident I know how to use my inhaler:

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?
Out of 25.