Adolygiad Asthma

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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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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.
Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

On Target

You scored

Your asthma appears to have been reasonably well controlled during the past 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

Well Done

You scored

Your asthma appears to have been under control over the last 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

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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?: *

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

If you’re not using an asthma action plan yet, it’s easy to get started:

Download an asthma action plan here. If you can, print out a copy to take to your GP or asthma nurse.
Book an asthma appointment with your GP or asthma nurse.
At the appointment, talk through the plan with your GP or asthma nurse and fill it in together. You can do this by telephone or video call too if your appointment isn’t in the surgery. Ask them to save a copy onto your notes and send it to you on email, SMS or WhatsApp.

Do you have a peak flow meter?: *

Would you like us to prescribe a peak flow meter to go to your nominated chemist?: *

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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Adolygiad Asthma

Cwblhewch ein ffurflen ar-lein

Off Target

On Target

Well Done

Additional Questions

How to get an asthma action plan

Privacy Consent

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