Postcode: Less than 5 years ago When was your asthma diagnosed? More than 5 years ago More than 10 years ago Please provide a date, if known: In the last month, have you had any No difficulty sleeping because of your asthma Yes, every day symptoms (including cough)? Yes, 1-2 times each week Yes, 1-2 times each month Yes, 1-2 times each year Yes, see below for details Details of sleeping difficulties: In the last month, have you had any of your usual asthma No symptoms during the day (cough, wheeze, chest tightness or Yes, everyday breathlessness)? Yes, 1-2 times each week Please give details of your daytime asthma symptoms: In the last has your asthma interfered with your usual No activities (e.g. housework, work, school etc)? Yes If Yes, please give details: Fields marked with a red asterisk are compulsory. Daily Weekly How often do you use your Reliever inhaler (Ventolin)? * If you are using your blue inhaler more than 3 times a week on a regular basis, Monthly you will need a to face” review “face Annually Other, see below for details Details of inhaler use (please inform us of any concerns regarding your blue inhaler use): No Are you happy with your Preventer inhaler and how to use it correctly? Yes If you are not, did you know that there is on online demonstration on the Asthma UK website or, you could pop in and see your local pharmacist or the surgery to have this assessed. Correct inhaler technique is very important in the management of your asthma. No Are aware of correct mouth hygiene when Contact the surgery for an appointment using your Preventer inhaler? Yes
Postcode: When was your asthma diagnosed? Less than 5 years ago More than 5 years ago More than 10 years ago Please provide a date, if known: In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? No Yes, every day Yes, 1-2 times each week Yes, 1-2 times each month Yes, 1-2 times each year Yes, see below for details Details of sleeping difficulties: In the last month, have you had any of your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? No Yes, everyday Yes, 1-2 times each week Please give details of your daytime asthma symptoms: In the last has your asthma interfered with your usual activities (e.g. housework, work, school etc)? No Yes If Yes, please give details: Fields marked with a red asterisk are compulsory. How often do you use your Reliever inhaler (Ventolin)? * If you are using your blue inhaler more than 3 times a week on a regular basis, you will need a “face to face” review Daily Weekly Monthly Annually Other, see below for details Details of inhaler use (please inform us of any concerns regarding your blue inhaler use): Are you happy with your Preventer inhaler and how to use it correctly? No Yes If you are not, did you know that there is on online demonstration on the Asthma UK website or, you could pop in and see your local pharmacist or the surgery to have this assessed. Correct inhaler technique is very important in the management of your asthma. Are aware of correct mouth hygiene when using your Preventer inhaler? No Contact the surgery for an appointment Yes