Asthma Annual Review Questionnaire

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

Asthma Questionnaire

Patient Name

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you experiencing your usual asthma symptoms during the day?

Is your asthma disturbing your sleep?

Does your asthma limit your everyday activities? E.g. school / work / housework?

Are you using your blue/reliever inhaler more than once a day? E.g. salbutamol, terbutaline?

Number of asthma exacerbations in the past year?

An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation.

Are you a Smoker?

We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044

Asthma Question Test

Question 1: During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home?

Question 2: During the last 4 weeks, how often have you had shortness of breath?

Question 3: During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning?

Asthma Control Test

Question 4: During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)?

Question 5: How would you rate your asthma control during the last 4 weeks?

Total Score

Email Optional

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