Asthma Questionnaire

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? *

If you have a peak flow meter at home please submit your current Peak Flow Measurement (please refer to the website for a guide on measuring your peak flow accurately).

How would you rate your asthma control during the past 4 weeks? *

Within the last year, have you been admitted to hospital/attended A&E as a result of your asthma? *

Admitted to Hospital

Attended Accident & Emergency Department

None

Have you received the flu vaccination this year? *

Yes No

Please indicate your smoking status. *

Current cigarette smoker

Currently vape

Ex-smoker

Non-smoker

Please provide your current height and weight if known.

Please indicate your preference for an asthma review appointment. *

Consent

The Practice is currently striving towards an online booking system for appointments. If you have not registered for our online services please complete the consent below. The Practice will respond to you via email with your unique login details so that you may order your prescriptions online, and make appointments for specialist clinics.

I consent to the Practice storing the information I have provided in my medical records, *

Yes No

I consent to the Practice contacting me by text messages. *

Yes No

I consent to the Practice contacting me via the email address I have provided. *

Yes No

I consent to the Practice registering me for online services and consent to receive login details via the email address I have provided. *

Yes No

Further Information