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Winchcombe Medical Centre NHS GP Surgery in Cheltenham

Asthma review (adults)

Asthma Review

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.

Phone Number:

Email Address: *

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.

Asthma Control Score

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

All of the time – 1

Most of the time – 2

Some of the time – 3

A little of the time – 4

None of the time – 5

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

More than once a day – 1

Once a day – 2

3-6 times a week – 3

1-2 times a week – 4

Not at all – 5

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? *

4 or more times a week – 1

2-3 nights a week – 2

Once a week – 3

Once or twice – 4

Not at all – 5

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

3 or more times a day – 1

1-2 times a day – 2

2-3 times a week – 3

Once a week or less – 4

Not at all – 5

How would you rate your asthma control during the past 4 weeks? *