Skip to main content

Asthma review (adults)

Asthma (adults)

Form summary

Asthma control questions

In the last month, how often did your asthma cause symptoms at night? *
In the last month, how often did your asthma cause symptoms during the day? *
In the last month, how often did asthma limit your activities? *
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
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? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *
Since your last review, have you had any asthma exacerbations? *
An exacerbation is where your asthma symptoms get gradually or suddenly worse, your reliever inhaler is not helping and you need medical attention
For example, how many exacerbations you have had and what happened each time
Do you have any of the following triggers?
Select all options that are relevant to you
Do you have a personalised asthma care plan? *
Are you able to provide your latest peak flow reading?
l/min

Inhalers

Inhalers can help:

  • relieve symptoms when they occur (reliever inhalers)
  • stop symptoms developing (preventer inhalers)

Some people need an inhaler that does both (combination inhalers).

Watch a short video from Asthma UK to learn how to use your inhaler properly (opens in new tab)

Have you watched and understood the inhaler videos? *

Smoking status

What is your smoking status? *

Smoker

What type of tobacco or other product do you use mostly? *
How many cigarettes do you smoke on an average day? *
How many cigars do you smoke on an average day? *

When you quit smoking, good things start to happen. You can begin to see almost immediate improvements to your health.

It’s never too late to quit and it’s easier to stop smoking with the right support.

Get help with NHS Quit Smoking (opens in new tab)

Would you like to give up smoking? *

Ex-smoker

What type of tobacco or other product did you use mostly? *
How many cigarettes did you smoke on an average day? *
How many cigars did you smoke on an average day? *
Are you exposed to second hand smoke at home? *

More information

Is there anything you would like to discuss?
For example, about your asthma, lifestyle, medication, support
Terms and conditions *