Asthma Annual Review Questionnaire

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4 November 2026

Asthma Review

Please would you answer the questions on the form below and submit it 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.

Asthma Annual Review Form

Asthma Annual Review Questionnaire

Notify

First

Last

Date of Birth

Gender

Female

Male

Address

Contact Numbers

Email Address

Questions

1. When was your asthma diagnosed?

2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

Please give details of your sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?

Please give details of symptoms during the day:

4. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?

Yes

5. Have you ever had your peak flow measured at the surgery?

Yes

If 'Yes', do you know your best PEFR value?

6. Are you happy with your inhaler technique?

Yes

7. Have you ever smoked?

Yes

If 'Yes', please answer the following:

How many do you smoke each day?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Yes

Don't know

Do you smoke now?

Yes

If 'No', when did you quit?

Asthma Control Score

8. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

9. During the past 4 weeks, how often have you had shortness of breath?

10. 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?

11. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?

12. How would you rate your asthma control during the past 4 weeks?

Monday	9:00am to 5.00pm
Tuesday	9:00am to 5.00pm
Wednesday	9:00am to 5.00pm
Thursday	9:00am to 5.00pm
Friday	9:00am to 5.00pm
Saturday	Closed
Sunday	Closed

Asthma Review

Asthma Annual Review Form

Questions

Asthma Control Score

Related information

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