Annual Asthma Review Asthma Annual Review Questionnare You are due an Annual Asthma Review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well as filling in this form.Contact DetailsName First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Telephone Number OptionalAlternative Telephone Number OptionalAddress Street Address Optional Address Line 2 Optional Postcode Optional Email Enter Email Confirm Email QuestionnaireWhen was your asthma diagnosed?Less than 5 years agoMore than 5 years agoMore than 10 years agoIn the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?NoYes, every dayYes, 1 – 2 times each weekYes, 1 – 2 times each monthYes, 1 – 2 times each yearYes, see below for detailsDetails of sleeping difficulties: OptionalIn the last month, have you had your usual asthma syptoms (including cough)?NoYes, every dayYes, 1 – 2 times each weekYes, 1 – 2 times each monthYes, 1 – 2 times each yearYes, see below for detailsDetails of daytime symptoms: OptionalHave you ever had your peak flow measured at the surgery? No Yes In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? No Yes If yes, do you know your best PEFR value? Optional Are you happy with your inhaler technique? No Yes 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.Have you ever smoked No Yes Used to How many do you smoke per day? No Yes There are plenty of options available to help you quit. Is this something you would like us to contact you about? No Yes When did you quit? Optional Asthma Control ScoreDuring the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?1 – All of the time2 – Most of the time3 – Some of the time4 – A Little of the Time5 – None of the time / NeverDuring the past 4 weeks, how often have you had shortness of breath?1 – More than Once per day2 – Once per day3 – 3-6 times per week4 – 1-2 times per week5 – None at allDuring 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?1 – 4 or more times in a week2 – 2-3 Nights per week3 – Once a week4 – Once or Twice5 – Not at allDuring the past 4 weeks, how often have you used your reliever inhaler (usually blue)?1 – 3 or more times per day2 – 1-2 Times a day3 – 2-3 times a week4 – Once a week or less5 – Not at allHow would you rate your asthma control during the past 4 weeks?1 – Not controlled2 – Poorly controlled3 – Somewhat controlled4 – Well controlled5 – Completely controlledNote: By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information. Personal Information Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.