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Asthma review questionnaire

You should be having a review every year (every 6 months for children), even if you are happy with your asthma treatment. It's a chance to talk about any triggers or symptoms, update your written asthma action plan and check your inhaler technique.

This form is  used for your annual asthma review. Please answer the questions to allow your health care professional to assess your asthma.

Asthma review

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, shortness of breath, chest tightness or pain) 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 (usually the blue inhaler) or nebuliser medication?
How would you rate your asthma control during the past 4 weeks?
An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention (find more information on https://www.nhs.uk/conditions/asthma/asthma-attack/)
Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery.
What is your smoking status?
Does anyone else in your household smoke? (if patient is 19 years old or younger)
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
Please indicate your surgery