Asthma Annual Review Questionnaire

If you are due your annual asthma review please can you complete the form below.

If your asthma symptoms have changed or if you have any questions or concerns, please make an appointment with the respiratory nurse or doctor.

What happens at a review?

It’s a chance to check how you’re getting on with your asthma. You can discuss how to avoid any triggers that set off your asthma or concerns about side effects of your medicines.

Think about what you want to ask at the review, for instance:

Am I on the right dose of medicine?
Is my medicine working?
Is this the best inhaler for me?
Is my inhaler technique right? (Remember; to take your inhalers with you to show your technique!)
What situations seem to make my asthma worse?
What should I do in an asthma emergency/asthma attack?

Our Respiratory Nurse will also check your peak flow reading.

We look forward to seeing you for your Asthma Review. If you are not able to come into the Surgery we can also offer a telephone consultation with one of the nurses.

Asthma Action Plan

The step-by-step guide that helps you stay on top of your asthma. Download the appropriate action plan below:

Adult Asthma Action Plan

Child Asthma Action Plan

Use your Pharmacist

Your pharmacist is a useful source of information if you are having a problem with your Asthma.

Follow your personal asthma action plan. If your symptoms continue to get worse, make an urgent appointment to see your doctor or asthma nurse. Never be frightened of calling for help in an emergency.

If you take the right medicines properly you should rarely have asthma symptoms. Many people put up with lots of different asthma symptoms, sometimes without realising that it doesn’t have to be this way. By having a regular asthma review and using a personal asthma action plan you can get better control over your asthma, meaning you’re less likely to have asthma symptoms or an asthma attack.

Your asthma isn’t well controlled if you are:

Using your reliever inhaler more and more

Waking at night with wheezing, shortness of breath, a tight chest or coughing

Having to take time off work or school because of your asthma

Feeling that you can’t keep up with your normal day-to-day activities or exercise

SMOKING AND ASTHMA

Smoking can:

Make asthma medicines less effective,
Increase the risk of an asthma attack
Permanently damage your airways.

Stopping smoking can be difficult, but it will have a massive impact on your asthma. If you would like help to stop smoking, please contact the surgery.

If you are not, did you know there is an online demonstration on the Asthma UK website (https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/) or you could pop in and see our practice nurse for more advice.

Your Details

Name

Date of Birth

Address

Post Code

Home Phone

Mobile Phone

Review Questionnaire

When was your asthma diagnosed?

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

If yes, please provide details

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

If yes, please provide details

How often do you use your blue inhaler?

Please provide details of your inhaler use

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

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

If yes, if you know your best PEFR value please provide it here (in ml/min)

Are you happy with your inhaler technique?

Have you ever smoked?

If you answered yes, please answer the following questions.

Do you smoke now?

If yes, how many do you smoke each day?

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?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Grove Surgery • 200–202 Chadwell Heath Lane, Chadwell Heath, Romford , Essex , RM6 4YU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.