Asthma Review Form

Your Details

Name *

Date of Birth *

Phone Number *

Can we text you about your asthma review? *

Yes No

Asthma Review

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?) *

Do you have an Asthma Management Plan? *

Yes No

If you do have an Asthma Management plan, do you need this to be updated? *

Yes No

Since your last review, have you needed a course of steroid tablets to get your asthma under control? *

Yes No

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

Have you ever smoked? *

Yes No

If you smoke, how many do you smoke per day? *

Did you have a flu vaccination last flu season? *

Yes No

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *

All of the time - 1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

During the past 4 weeks, how often have you had shortness of breath? *

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

Not at all - 5

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? *

4 or more times a week - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

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

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5

What is your score? (Add up each of your five scores to get your total asthma control score) *

20-25 - On target. Your asthma appears to have been under control over the last 4 weeks. However, if you are experiencing any problems with your asthma, please make an appointment with Pam our asthma nurse.

16-19 - Off target. Your asthma may not be as well controlled as it could be. Please make an appointment with Pam our asthma nurse

<15 - Your asthma has not been controlled during the past 4 weeks. Please make an appointment straight away with Pam our Asthma nurse

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Asthma Review Form

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