Asthma Review

About This Form

If you are due an annual asthma review please answer the following questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or a Doctor as well.

Note:
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Contact Details

Name:

Date of Birth:

Home Phone:

Mobile Phone:

Email:

Address:

Postcode:

Questionnaire

When was your asthma diagnosed?

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Details of sleeping difficulties:

In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

How often do you use your blue inhaler?

Details of inhaler use:

In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Have you ever had your peak flow measured at the surgery?

If yes, do you know your best PEFR valueml/min

Are you happy with your inhaler technique?

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice. https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/

Have you ever smoked?

If 'Yes', please answer the following:

Do you smoke now?

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Apples Medical Centre • East Mill Lane, Sherborne, Dorset, DT9 3DG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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