Asthma Review

Please use this form to review your asthma. Our nurses will then get back to you by online message or phone call. We will arrange a face-to-face appointment if needed.

We aim to respond within 1-2 weeks. If you need help with your asthma within a few days, please use the Get Help for any Health Problem form.

Asthma Review - New

About your symptoms

In the last month have you had difficulty sleeping due to your asthma (including cough)? *
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Calculate your 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? *

If your score is less than 20:

Off target

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.

If your score is between 20 and 24:

On target

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.

If your score is 25+:

Well done

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.

Additional Questions

Please complete the additional questions below and then press submit to send your review to your Doctor.

Additional Questions

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

Please visit SmokeFree Norfolk http://www.smokefreenorfolk.nhs.uk/ for help with quitting.

Did you have a flu vaccination last flu season?
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): *

Next Steps

What would you like the practice to do now? *

Our nurse might still want to contact you about your asthma.

How would you prefer our nurses to contact you? *