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.

For patients aged under 12, please contact the surgery for a review appointment.

About You

If you are completing this form for someone else i.e. a child aged 12 - 15, please state your name and relationship.

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:

Your Asthma Review

Has your condition changed in the last year? *

Yes

No

Please specify: *

In the last month have you had difficulty sleeping due to your asthma (including cough)? *

Yes

No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *

Yes

No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *

Yes

No

How often do you need to use your reliever (blue) inhaler? *

Never

1-2 times a month

1-2 times a week

3 or more times a week

2+ times a day

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? *

Yes

No

Please give details:

Have you been prescribed oral steroids (i.e. prednisolone) in the past 2 years? You may have been given these by someone at the surgery or a hospital. *

Yes

No

Do you smoke? *

Yes

No

Do you want to quit?

Yes

No

Which of these applies to you?

Ex-Smoker

Never smoked

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

Do you use a spacer device?

Yes

No

It is recommended that you replace your spacer every 12 months - please request this with your next prescription.

Please list the inhalers you use:

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 2 weeks, please contact us.