Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. A healthcare professional at the practice will review your form.

Asthma is a long-term condition that affects your airways – the tubes that take air to your lungs when you breathe.

If you have asthma your airways are sensitive, and react to triggers.

This reaction usually causes symptoms such as coughing, wheezing and breathlessness. It can also cause an ‘asthma attack’, when symptoms become more severe.

The best way to stop your asthma causing symptoms is to stick to a regular routine of taking your preventer medication.

By completing an asthma review each year, you can work with your healthcare professional to make sure you are on the right medicine to keep asthma symptoms under control.

Please visit Asthma UK: What is asthma? for more information about asthma.

If your symptoms are becoming worse or you have any concerns please make an appointment.

Asthma Review

Asthma Review

Please only use this form if you are 12 years or older. For children younger than 12 years, please use the Child Asthma Review.

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Part 1

These questions are about how well your asthma has been controlled in the last 4 weeks and give a score, which can be viewed on the next page.

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 (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *