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.

Asthma Review (new)

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.

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

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

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? *