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.

Please double check you've entered the correct email address

May be used to identify you

Asthma Control Score

(1) During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?: *

(2) During the past 4 weeks, how often have you had shortness of breath?: *

(3) 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?: *

(4) During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? : *

(5) How would you rate your asthma control during the past 4 weeks?: *

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

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Additional Questions

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

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?: *

Would you like help quitting?: *

Are you exposed to second-hand smoke?: *

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

Please select the types of inhalers that you use: *

Do you have a personal asthma plan?: *

How to get an asthma action plan

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

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.
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

Have you ever had your peak flow measured at the surgery?: *

Enter value or "Don't know"

Do you have your own peak flow meter?: *

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 https://www.nhs.uk/conditions/peak-flow-test/

How to use your inhaler Good inhaler technique is really important to make sure your medication reaches the right parts of your lungs. Please take a moment to watch the videos on Asthma UK

Please let us know that you have watched and understood the video(s): *

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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CONTACT DETAILS

Bridge Street Medical Centre
2 All Saints Passage
(Off Bridge Street)
Cambridge
CB2 3LS

Tel: 01223 652 671

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Asthma Review Form

Off target

On target

Well done

Additional Questions

How to get an asthma action plan

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