Asthma Review Full name Date of birth Phone number Security question In which month did you last see a doctor/nurse at this surgery? Do you take any prescribed medicines? Can you tell me what they are? Have you had an operation in hospital? Can you remember when and what it was for? Answer Your asthma review In the last month have you had difficulty sleeping due to your asthma (including cough)? Yes No Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? Yes No Yes No Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? Yes No How often do you need to use your reliever inhaler? Never 1-2 times a month 1-2 times a week 1-2 times a day 2+ times a day 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? Yes No Since your last review, have you needed a course of steroid tablets to get your asthma under control? Yes No Do you smoke? Yes No Did you have a flu vaccination last flu season? Yes No Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?): Please note that the details you give will be used to update your medical records. Consent for storing submitted data Consent for storing submitted data