Asthma Review

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 ensure you check your Spam/Junk email folder for any replies. An appointment/reply will be sent back to you via an email.

Please visit the following link for patient Self-management apps to support people living with Asthma or COPD:

Asthma Review

Asthma Review

Have you been asked by the practice to complete this online review form? *
Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

Patient Details

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

In Metres
In Kg
Please note: BMI calculator is only for patients aged 18 and over.

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? *