Asthma Review Form

Enter your full name
Date of Birth
Enter your postcode
1. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school, or home?
2. During the past 4 weeks, how often have you had shortness of breath?
3. During the past 4 weeks, how often did you asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or your nebuliser medication?
5. How would you rate your asthma control during the past 4 weeks?
An exacerbation is where your symptoms got worse, your reliever did not help, and you needed to seek medical attention.
Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP Surgery.
8. What is your smoking status?
Please enter any comments that you feel are relevant.
This field is for validation purposes and should be left unchanged.