Asthma Review Form RMP

Please only complete the following questionnaire if requested by your GP practice as part of your routine asthma review.

Last Updated: 17/07/2023

Your Details

Name *

Date of Birth *

Address *

Phone Number

Email Address *

Form completed by

Asthma review

How many asthma exacerbations (attacks) have you had in the past year? *

How many times have you attended Accident and Emergency Department since your last asthma review? *

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly.

Asthma UK Inhaler videos https://www.asthmaandlung.org.uk/living-with/inhaler-videos

I have watched the above relevant inhaler technique video and am happy with my inhaler technique *

Yes

Lifestyle - Smoking

Asthma Control Score

The asthma control test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled. If you are 12 years or older, please complete the questions below.

Once you have completed the test, please calculate your score to work out what your score is and what it means.

Further questions and consent

When you have completed the form please click submit below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and you other medical conditions you will be contacted if you need to be seen in clinic for further assessment. Should you symptoms change, please seek medical advice and book an appointment if required.

I have the following questions that I would like to raise with my Asthma Nurse or GP

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. I consent to the practice collecting and storing my data from this form. *

Yes No

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Asthma Review Form RMP

Further Information