Contact Details

Name

Address

Postcode

Date of Birth

Home Phone Number 

Mobile Phone Number 

Email Address 

Questionnaire

1. When was your asthma diagnosed? Less than 5 years agoOver 5 years agoMore than 10 years ago

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

Details of sleeping difficulties:

3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? NoYesevery dayYes1-2 times each weekYes1-2 times each monthYes1-2 times each year.Yessee elow for details

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?) YesNo

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

If yes, do you know your best PEFR value ml/min

6. Are you happy with your inhaler technique? YesNo

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

7. Have you ever smoked? YesNo

If 'Yes', please answer the following:

Do you smoke now? YesNo

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

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

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? All of the time - 1Most of the time - 2Some of the time - 3A little of the time - 4None of the time - 5

9. During the past 4 weeks, how often have you had shortness of breath? More than once per day - 1Once per day - 23-6 times per week - 31-2 times per week - 4None at all - 5

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? 4 or more times a week - 12-3 nights a week - 2Once a week - 3Once or twice - 4Not at all - 5

11. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? 3 or more times a day -11-2 times a day - 22-3 times a week - 3Once a week or less - 4Not at all - 5

12. How would you rate your asthma control during the past 4 weeks? Not controlled -1Poorly Controlled - 2Somewhat controlled - 3Well Controlled - 4Completely Controlled - 5

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