Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. Depending upon your review, you will be contacted if you need to be seen in clinic for a further assessment. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Please see the following websites for more information on Asthma that you may find useful:

Asthma Review

Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Your Asthma

How often does your asthma cause symptoms during the day?
How often does your asthma cause symptoms at night?
How often does your asthma limit your activities?
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?

Your Lifestyle - Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *