The Beeches Medical Centre - Annual Asthma Review Questionnaire
 

1. What is your name?

We need this information so we can match your responses to your medical record. *

 

2. What is your date of birth?
Example - Please enter 06.02.1984, if your date of birth is the 6th February 1984.

We need this information so we can match your responses to your medical record. *

 

3. Please select one of the following with regards to your smoking status.

 

4. If you currently smoke are you interested in trying to quit?

 

5. How many asthma attacks have you had in the last 12 months? *

0123456+
 

6. How compliant are you with your inhaler or how would you rate your technique?

On completing this questionnaire, we will send you details on how to use an inhaler correctly.
*

 

7. During the past 4 weeks, how often did your asthma prevent you from getting as much done as possible at work, school or home? *

 

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

 

9. During the past 4 weeks, how often does your asthma symptoms wake you up during the night or early morning? *

 

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

 

11. During the past 4 weeks, how would you rate your asthma control? *

 

12. With regards to your asthma, during the day, does your asthma ever effect you?
Please tick one of the following:

 

13. With regards to your asthma, does your asthma ever disturb your sleep.
Please select one of the following

 

14. With regards to your asthma, does it ever limit your activities?
Please select one of the following:

 

15. Do you feel your asthma is well controlled at the moment?
Please select one of the following?

PLEASE NOTE - If your asthma is not well controlled one of our practice nurses will contact you for a review.

Check out our survey templates or create your own.