Asthma Review

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Asthma Review

* Indicates required field

Name *

DOB (dd/mm/yy) *

Contact number *

How many asthma exacerbations have you had in the past 12 months (an exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention)Untitled *

Smoking status *

Current smoker Ex smoker Never smoked

How many cigarettes /day *

if applicable

When did you stop? *

If applicable

During the last 4 weeks, how much did your asthma prevent you from getting as much done at work, school or home? *

All the time Most of the time Some of the time A little of the time None of the time

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

More than once a day Once a day 3-6 times a week 1-2 times a week None at all

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 in the morning? *

4 or more times a week 2-3 times a week Once a week Once or twice None at all

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

3 or more times a day 1-2 times a day 2-3 times a week Once a week or less Not at all

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

Not controlled Poorly controlled Somewhat controlled Well controlled Completely controlled

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