Asthma Review Questionnaire

Full name*

Your date of birth*

In the last month/week, have you had difficulty sleeping due to your asthma (including cough symptoms)?*

Not at all
1-2 Nights a week
Most nights

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

No
1-2 per month
1-2 per week
Most days

Has your asthma interfered with your usual daily activities (eg school, work, housework)?*

No
1-2 per month
1-2 per week
Most days

Please select your current smoking status from the drop down list*

If you are ready or thinking about stopping smoking for further information and support please visit our NHS Smokefree Support Service page which can be found under the Services heading on our main menu.

Consent*

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

I agree to the privacy policy.

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