Asthma Review

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

Asthma Review Questionnaire

Asthma Review Questionnaire

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Asthma Review

Please complete the following questions to allow your health care professional to assess your asthma.

This questionnaire is for a routine review of your symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately

How often does your asthma cause symptoms during the day? *
How often does your asthma cause symptoms at night? *
How often does you asthma limit your activities? *

Lifestyle - Alcohol

To work out alcohol units, please visit:

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day drinking?
How oftem have you had 6 or more units if female, or 8 or more if male, on a single occassion in the last year?

Lifestyle - Smoking

Do you smoke?
Do you use an e-cigarette?
Would you like help to quit smoking?

for further information on giving up smoking please visit:

Further Questions

Please see the following links for further information on asthma that you may find useful:

NHS Choices


Asthma UK

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? *
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 (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *