ASTHMA REVIEW

Please fill out the questions below.

Personal Details

We can only accept height in cm and weight in kg. Please click here for a converter.

How much has your asthma kept you from getting things done at work/school/home?

Asthma Control Test

How often have you been short of breath?

How often have asthma symptoms woken you at night or early in the morning?

How often have you used your reliever inhaler or rescue medication e.g. Salbutamol?

How would you rate your asthma control?

Additional Questions

How many times in the last year have you experienced exacerbations in your asthma?

What is your current smoking status?

Are you happy with your Asthma management?

If you would like a review and want to read some information beforehand, please refer to the Asthma UK website for information about managing your asthma and plans you can follow to help keep your symptoms in check:

Asthma UK

Are there any other details you would like to add?

I understand this form is not for Urgent Care. I am happy for Chartfield to contact me as appropriate and for this information to be entered into my medical record. I am submitting this information for myself or as the authorised proxy of someone else.

Please complete all necessary fields.