KLINIK ACCESS

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Asthma Review Form

Asthma Review
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Please use format day/month/year e.g. 12/05/1979

Your Asthma Review

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
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? *
During the past 4 weeks, how often do you use your reliever (blue) inhaler? *
How would you rate your asthma control during the past 4 weeks? *
Automatically calculated from the answers above
In the past 12 months, how many flare-ups/exacerbations of your asthma have you had? *
Do you have a Peak Flow Meter at home? *
Have you received any education from your asthma nurse on how to use your inhalers correctly?
Do you have a self-management plan? *
Do you have any specific issues with your asthma which you would like to discuss further? *

Weight, Height and BMI

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Lifestyle

1 unit = 1 small glass of wine, half pint of beer/lager, single measure of spirit/whisky/vodka etc
Do you smoke? *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.