Asthma Review Patient Name First Last Date of Birth Day Month Year Address Street Address Address Line 2 City ZIP / Postal Code How often does your asthma case symptoms during the day?No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days)How often does your asthma cause symptoms at night?No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most nights)How often does your asthma limit your everyday activities? e.g. school / work / houseworkNo / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days)Number of asthma exacerbations (attacks) have you had in the past year?Please enter a number from 0 to 999999.An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation.How many times have you attended Accident and Emergency Department since your last asthma review?Please enter a number from 0 to 999999.What triggers your asthma? Animals Airborne dust Cold air Damp Dust mites Emotion Exercise Humidity Perfume Pollen Respiratory infection Seasonal Tobacco smoke Warm air Wind No triggers identified Inhaler TechniqueIt 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: Click Here for Inhaler VideosI have watched the above relevant inhaler technique videos and am happy with my inhaler technique. Yes No Lifestyle – SmokingAre you a Smoker?Never Smoked TobaccoEx-smokerTrivial smoker (less than 1 cigarette per day)Light smoker (1-9 cigarettes per day)Moderate smoker (10-19 cigarettes per day)Heavy smoker (20-39 cigarettes per day)Very heavy smoker (40 or more cigarettes per day)We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044Do you use an e-cigarette? No Optional Ex-User Optional Yes Optional Asthma Control Test ScoreThe Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled.During the last 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?All the timeMost of the timeSome of the timeA little of the timeNone of the timeDuring the last 4 weeks, how often have you had shortness of breath?More than once a dayOnce a day3 – 6 times a weekOnce or twice a weekNot at allDuring the last 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or early in the morning?4 or more times a week2 – 3 nights a weekOnce a weekOnce or twiceNot at allDuring the last 4 weeks, how often have you used your reliever inhaler (usually blue)?3 or More times a day1 – 2 times a day2 – 3 times a weekOnce a week or lessNot at AllHow would you rate your asthma control during the last 4 weeks?Not ControlledPoorly ControlledSomewhat ControlledWell ControlledCompletely ControlledTotal ScoreWarning advice: Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.Further QuestionsPlease list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device)? OptionalWould you like a personalised asthma action plan? Yes No I have the following questions that I would like to raise with my Asthma Nurse or Doctor: OptionalPlease see the following links for further information on asthma that you may find useful:Asthma NHS UKPatient.Info GuidanceAsthma UK infoComments OptionalThis field is for validation purposes and should be left unchanged.
