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Asthma Annual Review

Word cloud asthma related. Healthcare concept of respiratory system disease.

Asthma Annual Review

If 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. Fields marked with an asterisk are compulsory. 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.
  • Date Format: DD slash MM slash YYYY
  • Questionnaire (8 Questions):

    Please answers as many of the questions as you can
  • In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?
  • Please provide details of sleeping difficulties
  • In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?
  • e.g. housework, work, school etc?
  • If you are not, use the link to see an online video on inhaler technique: https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/
  • Approximate date
  • There are many options available to help you to quit smoking. Is this something that you would like us to contact you about?
  • This field is for validation purposes and should be left unchanged.