Asthma review quesionnaire Consent for storing submitted data Consent for storing submitted data Name Date of birth Telephone Email Address Postcode When was your asthma diagnosed? Less than 5 years ago More than 5 years ago Over 10 years ago In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? No Yes, every day Yes, 1-2 times a week Yes, 1-2 times a month Yes, see below for details Details of sleeping difficulties: In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? No Yes, every day Yes, 1-2 times a week Yes, 1-2 times a month Yes, see blow for details Details of symptoms during the day: In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? Yes No Have you ever had your peak flow measured at the surgery? Yes No If yes, do you know your best PEFR value (ml/min)? Are you happy with your inhaler technique? Yes No Have you ever smoked? Yes No If yes, do you smoke now? Yes No If yes, how many do you smoke a day? If no, when did you quit? During 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 time 2 - Most of the time 3 - Some of the time 4 - A little of the time 5 - None of the time During the past 4 weeks, how often have you had shortness of breath? 1 - More than once a day 2 - Once a day 3 - 3-6 times a week 4 - 1-2 times a week 5 - None at all During 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 - More than 4 times per week 2 - 2-3 times a week 3 - Once a week 4 - Once or twice 5 - Not at all During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? 1 - More than 3 times a day 2- 1-2 times a day 3 - 2-3 times a day 4 - Once a week or less 5 - Not at all How would you rate your asthma control during the past 4 weeks? 1 - Not controlled 2 - Poorly controlled 3 - Somewhat controlled 4 - Well controlled 5 - Completely controlled