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Asthma

Please answer the following questions so that we may better understand how your asthma is affecting you. Poorly controlled asthma can have serious and long-term health impacts. This information allows us to help you better manage your condition. We ask that you fill this out once a year. We will invite you to make an appointment if we feel you need to make changes to your treatment.

Asthma Review Form
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Personal Details
Name*
First name Surname
Date of Birth*
Date Format: DD slash MM slash YYYY

Phone Number*

Asthma Related Questions
Do you have asthma?
How often does your asthma cause symptoms during the day?*
How often does your asthma cause symptoms at night?*
How often does your asthma limit your activities?*
How many times a week, on average, do you need to use your reliever (Blue – Ventolin/Salbutamol)?*
How many asthma exacerbations have you had in the past 12 months?*
An exacerbation is where your symptoms got worse, your reliever did not help, and you needed to seek medical attention. For more information about asthma attacks, visit the NHS website.
What is your smoking status?*
Do you have any further information about your asthma that you feel is relevant to this review?
Please note that your answers will not be seen immediately. You should direct any urgent queries to your GP by contacting the practice.
Your Personal Data*
Please note that any personal data you provide will be treated in the strictest of confidence and in full compliance with GDPR legislation. Any identifying information you specify will be held by us for the sole purpose of answering your enquiry. The data will be stored on our server until such time that it is no longer required. If you are happy for us to use and store your data in this way, Please tick the box below. Full details are available in our Privacy Policy.
I consent to Clapham Family Practice storing and using my personal data for the sole purpose of addressing my enquiry.

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Asthma Review Form

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Asthma Related Questions