Asthma Review

Thank you for taking the time to complete your annual asthma review.

You will need (if available) your weight, blood pressure and an up to date Peak Flow Reading.

Don’t worry if these are not available, the information you provide will allow us to assess how well controlled your asthma is and make recommendations where necessary.

Asthma Remote Review

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 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? *

In the last month:

Have you had difficulty sleeping because of your asthma symptoms (including cough)? *
Frequency: *
Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? *
Frequency: *
Has your asthma interfered with your usual activities (for example housework, work or school)? *
Frequency: *

Further Questions

Have you had an exacerbation of asthma (needed a course of oral steroids or to increase your preventer use for a few days) this year? *
Do you currently smoke? *

Asthma Management Plan

The questions below will help us produce an asthma management plan for you as recommended by Asthma UK.
Do you know of any triggers for your asthma? *
Avoiding triggers and taking your preventer can reduce the number of exacerbations you may have.

Peak Flow Readings

Peak flow readings can help let you know how well your asthma is controlled and how severe an exacerbation is.

Please watch this video which explains how to measure your peak flow.

Do you have a peak flow meter? *
You can buy a peak flow meter from a pharmacy or we can offer one on prescription.
Do you need a prescription for a peak flow meter? *

Preventer Inhalers

Preventer inhalers if taken regularly can keep your asthma under control.

Reliever Inhalers

Reliever inhalers are taken when you have symptoms to provide fast relief.

If Your Asthma Gets Worse

If you feel your asthma is getting worse, you should contact the surgery to speak to our asthma nurse by phone as soon as possible.

Signs that your asthma may be getting worse are:

  • Increased wheeze or shortness of breath
  • Taking your reliever inhaler more than normal
  • Waking at night due to asthma symptoms
  • Finding your daily activities are limited by your asthma
  • Using your reliever inhaler more than 3 times a week
  • If your peak flow readings are between 50-70% of your best

You may be having an asthma attack if you are using your reliever inhaler more than every 4 hours or needing more than 10 puffs.

You should seek medical advice either by contacting the surgery by phone/111 or 999 if you feel you need immediate help.

Your asthma plan is important as it provides clear advice about what to do in these situations and when to seek medical advice.

Flu Jab

You should have a flu jab every year. It is important as you may be at higher risk of becoming ill and requiring hospital treatment as an asthmatic.

Would you like to decline a flu jab? *

Inhaler Techniques

Inhaler technique is very important. If not used properly they will not be effective at treating your asthma and preventing asthma attacks.

Please follow visit www.asthma.org.uk/advice/inhaler-videos to watch a demonstration.

*

If you would like further help with your inhaler technique or just aren't sure please take your inhalers to the local pharmacist who can demonstrate how you can use your inhalers more effectively and let us know if they feel you need a different type.

What Happens Next

We will use your answers to complete an asthma management plan that we will forward on.

You may already have one but it is recommended that it is reviewed every year.

An example form can be found at www.asthma.org.uk.

Thank you for taking the time to answer these questions.

Our nursing team will review your information and update your records and reply with any relevant advice.

What would you like to happen next? *
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