This form is to be used as a pre-check for your routine asthma review, to decide if you need further assessment.
If you feel that you need urgent medical attention for your asthma or need medication urgently, please submit the form and contact the surgery in the normal way. If you need urgent medical attention when the surgery is closed, please ring 111.
Adult Asthma Control Test
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?
During the past 4 weeks, how often have you had shortness of breath?
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?
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
How would you rate your asthma control during the past 4 weeks?
Child Asthma Control Test – Child to Answer
How is your asthma today?
How much of a problem is your asthma when you run, exercise or play sports?
Do you cough because of your asthma?
Do you wake up during the night because of your asthma?
Child Asthma Control Test – Parent/Guardian to Answer
During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
During the last 4 weeks, how many days did your child wake up during the night because of asthma?
Do you want to quit smoking?
Do you have a peak flow meter?
We can prescribe you a peak flow meter – please contact the surgery to request this and collect from your nominated pharmacy with your next prescription. Please see www.asthma.org.uk/peak-flow for information on peak flow meters.
Please confirm you have checked
Please note: Most people with well-controlled asthma will only need a face to face asthma review once every 3 years. We will advise you if you need to attend or not. If you have not heard from us within 28 days, please contact us.
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