Asthma Review - Oakwood Lane Medical Practice

Name *

Date of Birth *

Phone *

Email

Address *

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1. When was your asthma diagnosed?

2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

4. How often do you use your blue inhaler?

Details of inhaler use:

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

No

Yes

6. Have you ever had your peak flow measured at the surgery?

No

Yes

If yes, do you know your best PEFR value

7. Are you happy with your inhaler technique?

No

Yes

8. Have you ever smoked?

No

Yes

If ‘Yes’ how many do you smoke each day?

If ‘Yes’, please answer the following: Do you smoke now?

No

yes

If ‘No’ when did you quit? If ‘No’ when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

No

Yes