Asthma Review Form

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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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May be used to identify you
Asthma Control Score
Your Score

Off target

You scored 

Your asthma may not have been controlled during the past 4 weeks.
Please contact the surgery to arrange a phone appointment for an asthma review with your GP

On target

You scored 

Your asthma appears to have been reasonably well controlled during the past 4 weeks.
We may contact you by phone or sms to ensure you have an asthma plan in place

Well done

You scored 

Your asthma appears to have been under control over the last 4 weeks.
We may contact you by SMS or phone to ensure you have a personalised asthma plan

Additional Questions

Additional Questions

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

How to get an asthma action plan

Asthma action plans have been shown to help with managing asthma.

  1. If you know your usual peak flow, enter it below and we will use it to compile a personal asthma plan for you. We will send you the plan by sms.
  2. If you don't know your usual peak flow, we may need to contact you for a review; please do use the form below to request a peak flow meter to help you monitor your asthma 
Enter value or "Don't know"
Enter value or "Don't know"

It is really useful to be able to monitor your own peak flow. We will prescribe a meter to go to your nominated chemist, please allow 72 hours for collection. Please see guidance for how to use your peak flow meter here

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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