ASTHMA HEALTH REVIEW

Personal Details

Full Name: Date of Birth: Postcode:

Are you currently using medication for asthma?

Yes

If not, when was the last time that you used your medication?

How many times a day do you use your reliever (salbutamol)?

If you have a peak flow meter, what is your expiratory rate? Please note: the best, i.e. the highest, of three attempts.

Do you use a spacer device with your inhaler?

Yes

Have you been admitted to hospital because of your asthma in the past year?

Yes

Daytime Symptoms

Limiting Activities

Disturbing Sleep

Smoking habits?

Smoker

Never Smoked

Ex-Smoker

General Comments:

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form