Contact Details

Name

Address

Postcode

Date of Birth

Home Phone Number

Mobile Phone Number:

Email Address:

Questionnaire

1. When was your asthma diagnosed? Less than 5 years agoOver 5 years ago

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

Details of sleeping difficulties:

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

Details of symptoms during the day:

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

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

If yes, do you know your best PEFR value

If you are not, did you know there is an online demonstration on the https://www.asthma.org.uk/ website.  Click here to view, or you could pop in and see our practice nurse for more advice.

7. Have you ever smoked? YesNo

If 'Yes', please answer the following:

Do you smoke now? YesNo

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

If 'No' when did you quit? If 'No' when did you quit?

Asthma Control Score

8. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

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

10. 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? 

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

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

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