Asthma Review Asthma medication review First, a few details about yourself Last * Last Date of Birth * Name * First Preferred Contact details if we need any clarification (Email or telephone number) * Let’s assess your symptoms now 1. During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home? * All of the time Most of the time Some of the time A little of the time None of the time 2. During the last 4 weeks, how often have you had shortness of breath? * More than once a day Once a day 3-6 times a week Once or twice a week Not at all 3. During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning? * Four or more nights a week 2-3 nights a week once a week once or twice Not at all 4. During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)? * 3 or more times per day once or twice per day 2-3 times per week once a week or less Not at all 5. How would you rate your asthma control during the last 4 weeks? * Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled Control Score Have you had any exacerbation over last few months? Yes No Did you have to go to hospital? And finally look at ways to improve your asthma Do you smoke? Yes No Smoking makes asthma worse. Shall we send you the contact details of the smoking cessation clinic? Yes No If you catch the flu, it will be worse than for people without asthma. Vaccination helps. Are you interested in having the flu jab? Yes No If you would like information on how to manage your asthma please visit www.asthma.org.uk/advice/manage-your-asthma Submit
