Asthma Pre-review

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.

• If you need to re-check your inhaler technique, please see www.asthma.org.uk/advice/inhaler-videos
• If you need advice on what to do if you have an asthma attack, please see www.nhs.uk/conditions/asthma/asthma-attack
• Please see www.asthma.org.uk/peak-flow for information on peak flow meters

Your Details

Are you completing this review for someone else ie. a child under 16? *

Yes

No

Are you completing this review for a child aged 4-11? *

Yes

No

Please state your name and relationship to the person you are completing the form for: *

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Please provide at least one contact number or email address. By providing a mobile phone number and/or email address on this online form, we assume consent to reply by this method.

Do you have any communication/information needs relating to disability, impairment or sensory loss?

Yes

No

Please be specific:

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? *

All of the time - 1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

During the past 4 weeks, how often have you had shortness of breath? *

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

Not at all - 5

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 or more times a week - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

How would you rate your asthma control during the past 4 weeks? *

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5

Calculated Asthma Score (Adult):

Child Asthma Control Test - Child to Answer

How is your asthma today? *

Very Bad - 0

Bad - 1

Good - 2

Very Good - 3

How much of a problem is your asthma when you run, exercise or play sports? *

It is a big problem, I cannot do what I want to do - 0

It is a problem and I do not like it - 1

It is a little problem but it is okay - 2

It is not a problem - 3

Do you cough because of your asthma? *

Yes, all the time - 0

Yes, most of the time - 1

Yes, some of the time - 2

No, none of the time - 3

Do you wake up during the night because of your asthma? *

Yes, all the time - 0

Yes, most of the time - 1

Yes, some of the time - 2

No, none of the time - 3

Child Asthma Control Test - Parent/Guardian to Answer

During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *

None - 5

1 to 3 days - 4

4 to 10 days - 3

11 to 18 days - 2

19 to 24 days - 1

Everyday - 0

During the last 4 weeks, how many days did your child wheeze during the day because of asthma? *

None - 5

1 to 3 days - 4

4 to 10 days - 3

11 to 18 days - 2

19 to 24 days - 1

Everyday - 0

During the last 4 weeks, how many days did your child wake up during the night because of asthma? *

None - 5

1 to 3 days - 4

4 to 10 days - 3

11 to 18 days - 2

19 to 24 days - 1

Everyday - 0

Calculated Asthma Score (Child):

Additional Questions

Smoking Status: *

Smoker

Ex-smoker

Never smoked

Uses electronic cigarettes

Passive smoker

No known exposure to tobacco smoke

Do you want to quit?

Yes

No

Please contact LiveWell Dorset on 0800 8401 628 or visit www.livewelldorset.co.uk

How many exacerbations have you had in the last year?

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?

Yes

No

What is your best peak flow?

What is your current peak flow?

We will prescribe you a peak flow meter – please collect from your nominated pharmacy with your next prescription. Please see www.asthma.org.uk/peak-flow for information on peak flow meters.

When you have collected your meter, please send your best peak flow reading to quarterjack.surgery@nhs.net with your full name and date of birth.

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

*

I confirm I have checked the inhaler techniques

Please note that the details you give will be used to update your medical records. 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.

During the Covid-19 pandemic, we are reviewing most patients by telephone – you will be advised if you need to book a telephone consultation with the asthma nurse or doctor.