Adult Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms, please use this form. If your symptoms are deteriorating or you are having any concerns, please make an appointment with our Nurse.

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

Please note that you will need to have your inhalers and spacers available when attending for a face to face review or a video consultation.

Adult Asthma Review
Are you completing this form on behalf of: *

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.
Confirmation *
Smoking Status:
Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what's right for you. For more information visit the Smokefree website.

Smoker

Would you like help to give up smoking?

Ex smoker

Do you vape?
For applicable devices
e.g. 1.75
e.g. 60.6
Would like to be referred for help with weight loss?
Do you require a translator?

In the last month have you had difficulty sleeping due to your asthma (including cough)? *
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *