Asthma Review - The Grove Medical Centre

In the last month have you had difficulty sleeping due to your asthma (including cough)? *

Yes No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *

Yes No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *

Yes No

How often do you need to use your reliever inhaler? *

Yes No

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma? *

Yes No

Since your last review, have you needed a course of steroid tablets to get your asthma under control? *

Yes No

Do you smoke? * *

Yes No

Did you have a flu vaccination last flu season? *

Yes No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?): *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

Asthma Review Form

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