Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use the form below. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

First Name

Last Name

Date of Birth

Address

Street Address Address Line 2 Postcode

Are you experiencing your usual asthma symptoms during the day? *

Is your asthma disturbing your sleep? *

Does your asthma limit your everyday activities? E.g. school / work / housework? *

Are you using your blue/reliever inhaler more than once a day? E.g. salbutamol, terbutaline?

Number of asthma exacerbations in the past year? *

An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation.

Are you a Smoker? *

We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044