Asthma Review

 

Important

Please only complete this form if you have an asthma review booked and have been advised by the practice to submit this form.

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Asthma Review

Asthma Review 

What is an Asthma Review?

  • It is intended to measure and assess well you are managing your condition.

What does it involve?

  • There are 5 questions relating to different situations.
  • Once you have scored each question the values are added together to give an indication of how you are managing.
  • On reviewing your submission, a nurse may want to speak to you or arrange an appointment, please ensure we have the correct contact number for you so we can contact you as required.

Once received it can take up to 1 month to review your answers

  • Please only complete this form if you have an asthma review booked and been advised by the practice to submit this form.
  • If you are in need of urgent advice/treatment call the surgery or call 111
  • Call 999 in life threatening situations
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All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
May be used to identify you

Children must be aged 4 or over to take the Asthma Control Test.

This form is not suitable for those under 4 years so you cannot continue: *
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Asthma Questions

During the past 4 weeks

How often did your asthma prevent you from getting as much done at work, school or home?: *
How often have you had wheeze or shortness of breath?: *
How often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?: *
How often have you used your rescue inhaler (such as Salbutamol)?: *
How would you rate your asthma control during the past 4 weeks?: *

Have your child answer these questions

How is your asthma today?
  • Very Bad
  • Bad
  • Good
  • Very Good
How much of a problem is your asthma when you run, exercise or play sports?
  • Very It's a big problem, I can't do what I want to do
  • It's a problem and I don't like it
  • It's a little problem but it's okay
  • It's not a problem
Do you cough because of your asthma?
  • Yes, all of the time
  • Yes, most of the time
  • Yes, some of the time
  • No, none of the time
Do you wake up during the night because of your asthma?
  • Yes, all of the time
  • Yes, most of the time
  • Yes, some of the time
  • No, none of the time

Please complete the following questions on your own

During the past 4 weeks

How many days did your child have any daytime asthma symptoms?: *
How many days did you child wheeze during the day because of asthma?: *
How many days did your child wake up during the night because of asthma?:
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Well Done

, your score is 

Your asthma appears to have been under control over the past 4 weeks.

If you are experiencing any problems with your asthma

  • Book an appointment with a nurse or GP as soon as possible

On Target

, your score is 

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

If you are experiencing any problems with your asthma

  • Book an appointment with a nurse or GP as soon as possible

Off Target

, you have a score of 

Your asthma may not have been controlled during the past 4 weeks.

Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.

  • If you have symptoms, please book an appointment with a nurse or doctor as soon as possible or call 111
  • Alternative visit a pharmacist for further advice
  • Call 999 in life threatening situation.
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Exacerbation
Exacerbation means your asthma has become worse and you required antibiotic and / or oral steroid treatment
Is care provided by the chest clinic/asthma team at the hospital?: *
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Asthma Action Plan

Everyone with asthma can benefit from using an asthma action plan.

It tells you, and anyone with you:

  • which medicines are taken every day to prevent symptoms and cut the risk of an asthma attack
  • what to do if asthma symptoms are getting worse  
  • the emergency action to take if having an asthma attack and when to call 999.

Fill it in with a GP or asthma nurse, so it’s personalised.

Then take it along to all asthma appointments, including any out of hours appointments or A&E, so doctors or asthma nurses can help keep it up to date.

Information taken from the Asthma UK Website

“Experts recommend asthma action plans to look after asthma well and cut the risk of an asthma attack”

Dr Andy Whittamore, Asthma UK's in-house GP

Click here for more information about an asthma action plan

Is there an asthma plan already?:
Is an asthma plan required?: *

How to get an asthma action plan

If you’re not using an asthma action plan yet, it’s easy to get started with support from Asthma UK

 How to get an asthma action plan

Is there a peak flow meter at home?:
Do we need to prescribe a peak flow meter?:
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Medication
Is medication used (inhaler and / or tablet) for managing asthma?: *
if you are not sure, state the colour of the inhaler, please including how many puffs you take a day, and how often you take these
Is a spacer used with the inhalers?:
Is the spacer older than 12 months?:
Is a new spacer required, as this should be renewed on a yearly basis?:
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Inhaler Technique

How does good inhaler technique help you manage your asthma?

If you’re using your preventer inhaler as prescribed, and using the right inhaler technique, it can help you:

  • cut your risk of an asthma attack
  • feel less breathless climbing stairs
  • cope better with your usual asthma triggers
  • get a good night’s sleep
  • have less time off work
  • take part in exercise and family activities

Good inhaler technique can really make a difference to how well you manage your asthma. It could also mean you’ll be able to manage your asthma symptoms without needing to be prescribed higher doses.

Information taken from the Asthma UK Website

Inhaler

Click here for guides about using your inhalers

Click here for vidoes guides about using inhalers

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Asthma Attack

Having an Asthma Attack

What to do when you are having an Asthma Attack

Click here to find our what to do in an Asthma Attack

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Lifestyle

Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Smoking Status
Please choose from one of the following options: *
Stop Smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Interested in further advice and support on how to quit?: *
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Additional Questions
Since the last review, was there a need to see a doctor as an emergency or attend the A&E department of a hospital as a result of asthma symptoms?: *
Since the last review, was there a need for a course of steroid tablets to get asthma under control?: *
Please select the types of inhalers that are used : *
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