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Asthma review (adults)

Asthma Review (new)

Your Asthma

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?

Inhaler Technique

Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s):

Your Lifestyle – Alcohol

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

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

Additional alcohol consumption questions

How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Your Lifestyle – Smoking

Smoking status:
Do you use an e-Cigarette?
How many cigarettes did you smoke per day?
How many cigarettes do you smoke per day?
Would you like help to quit?

For further information, please see: www.nhs.uk/smokefree

Asthma Control Test Score

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled.

If you are 12 years or older, please complete the questions in this section.

How often did your asthma prevent you from getting as much done at work/school/home?
How often have you had shortness of breath?
How often did your asthma symptoms wake you up at night or early in the morning?
How often have you used your reliever inhaler (usually blue)?
How would you rate your asthma control?
Confirmation

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

Asthma (NHS website)

Patient.Info

Asthma UK

Follow-up

When you are happy with all your above answers, please submit this form.

Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.