Asthma review form

 

Please fill in as much information as you can about the current state of your asthma. Once submitted the information will be entered into your clinical record and reviewed by a Practice Nurse, usually within five working days. If there are no issues they will arrange for your medications to be reauthorised by your usual GP, otherwise they will give you a call to discuss your asthma over the phone.

    Personal Details

    Your Name:
    Your Date of Birth:
    Contact Tel Number:
    Your Email Address:

    Asthma Symptoms

    1. In the past 4 weeks, how often have your asthma symptoms (cough, wheeze, chest tightness or breathlessness) affected you during the day?
    More then once a dayOnce a day3 to 6 times a week1 to 2 times a weekNot at all
    2. In the past 4 weeks, how much of the time has your asthma interfered with your usual activities at home, work or school?
    All of the timeMost of the timeSome of the timeA little of the timeNone of the time
    3. In the last 4 weeks, how often have your asthma symptoms (cough, wheeze, chest tightness or breathlessness) caused you difficulty sleeping?
    4+ nights a week2 or 3 nights a weekOnce a week1 or 2 nights a monthNot at all
    4. In the past 4 weeks, how controlled has your asthma been?
    Not at allPoorlySomewhatWellCompletely
    5. What are your current asthma triggers?
    alcoholanimalscigarette smokecold airdampdustexercisefoodpollenpollutionrespiratory infectionstress or anxietywarm airunknown
    6. What inhalers do you currently use, and approx how often have you had to use them in the last 4 weeks?
    7. 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?
    YesNo

    Measurements

    Current height: m cm Current weight: kg
    (You can use a converter if you don't know your height and weight in these units)
    Most recent (and best) Peak Flow: L/min Date of reading:
    What is your current smoking status?
    If you are a current smoker, how much do you smoke a day?

    Self-Management Plan

    Do you have an NHS Lothian Asthma Self-Management Plan? YesNoDon't know
    If yes, do you understand and are you happy with the information it contains? YesNoDon't know
    If you answered no or don't know to either question, please consider making an appointment with one of our asthma nurses for a 20 min review.

    Other Information

    Is there any other information you would like to let us know about your asthma?

    Before clicking submit input this code: captcha