Asthma review (adults)

Section

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

What inhaler(s) do you have?

How often do you use each inhaler at present?

What colour preventer do you use:

For example, 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

Additional questions

Over the past year, have you had times when asthma symptoms have appeared every week?

Yes

No

For example, cough, wheeze, shortness of breath, waking at night, symptoms with or after exercise, needing to use your reliever inhaler

Please give details:

Do you know what triggered these symptoms?

Do you have any questions or concerns about your asthma?

Yes

No