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Asthma Review Form

Asthma Pre-review ACT

This form is to be used as a pre-check for your routine asthma review, to decide if you need further assessment.

If you feel that you need urgent medical attention for your asthma or need medication urgently, please submit the form and contact the surgery in the normal way. If you need urgent medical attention when the surgery is closed, please ring 111.

Your Details

Are you completing this review for someone else ie. a child under 16?
Are you completing this review for a child aged 4-11?
Please use format day/month/year e.g. 12/05/1979

Adult Asthma Control Test

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?
Automatically Calculated

Child Asthma Control Test – Child to Answer

How is your asthma today?
How much of a problem is your asthma when you run, exercise or play sports?
Do you cough because of your asthma?
Do you wake up during the night because of your asthma?

Child Asthma Control Test – Parent/Guardian to Answer

During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
During the last 4 weeks, how many days did your child wake up during the night because of asthma?
Automatically calculated

Additional Questions

Smoking Status
Do you want to quit smoking?
An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.
Do you have a peak flow meter?

We can prescribe you a peak flow meter – please contact the surgery to request this and collect from your nominated pharmacy with your next prescription. Please see www.asthma.org.uk/peak-flow for information on peak flow meters.

Inhaler Technique

Please check your inhaler technique here: www.asthma.org.uk/advice/inhaler-videos

Please confirm you have checked

Asthma Review

Please note: Most people with well-controlled asthma will only need a face to face asthma review once every 3 years. We will advise you if you need to attend or not. If you have not heard from us within 28 days, please contact us.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.