The White Rose Surgery

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Asthma Health Review

This form is used to screen your regular symptoms. If you have any worsening or acute symptoms (wheezing, tight chest, shortness of breath) then please seek medical attention.

All information is treated as confidential and secure. We use any answers to screen for uncontrolled asthma and will contact you accordingly.

Personal Details

Full Name Date of Birth Postcode

Asthma Health Review

1. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school, or home? 2. During the past 4 weeks, how often have you had shortness of breath? 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning? 4. During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or your nebuliser medication? 5. How would you rate your asthma control during the past 4 weeks? 6. How many exacerbations have you had in the past 12 months? An exacerbation is where your symptoms got worse, your reliever did not help, and you needed to seek medical attention. 7. Do you have any further information about your asthma that you feel is relevant? Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP Surgery. 8. What is your smoking status? 9. General Comments

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I confirm that I am a patient at The White Rose Surgery, South Elmsall, Yorkshire.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

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