13 Years and over (Adult) - Asthma Questionnaire

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Personal Details

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

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Asthma Control Score

We would be most grateful for an update on your asthma status.  We routinely collect this information annually on all our asthmatic patients, so I apologise if we have asked you any of these questions before, but it is essential we have current information.

Please think about the last four weeks when answering the next questions

Your Score

Off Target

You scored 

Your asthma may not have been controlled during the past 4 weeks.
Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

On Target

You scored 

Your asthma appears to have been reasonably well controlled during the past 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

Well Done

You scored 

Your asthma appears to have been under control over the last 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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