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The Limes Surgery NHS GP Surgery in Hertfordshire

Adult asthma review

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Your Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?

Yes

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes

How often do you need to use your reliever inhaler?

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes

Please give details:

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes

Do you smoke?

Yes

Did you have a flu vaccination last flu season?

Yes

Please 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?): *

I confirm that the information provided is accurate to the best of my knowledge.

Please note that the details you give will be used to update your medical records.

If you are human, leave this field blank.

8-14 Limes Court
Conduit Lane
Hoddesdon
Hertfordshire
EN11 8EP

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01992 464533

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