Asthma Questionnaire

Personal details

Title: *

Gender: *

First name: *

Last name: *

Date of birth: *

Mobile: *

Home telephone: *

Work telephone:

Email address: *

Post code: *

Address: *

Questionnaire

When was your asthma diagnosed?: *

In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?: *

Details of sleeping difficulties:

In the last month, have you had your usual asthma symptoms during the day? (e.g. cough, wheeze, chest tightness or breathlessness): *

Details of symptoms during the day:

How often do you use your blue inhaler?: *

Details of inhaler use:

In the last month has your asthma interfered with your usual activities
(e.g. housework, work, school etc)?: *

Have you ever had your peak flow measured at the surgery?: *

If yes, do you know your best PEFR value (ml/min)?:

Are you happy with your inhaler technique?: *

If you are NOT, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

Smoking history

Have you ever smoked?: *

If YES, please answer the following:

Do you smoke now?: *

If YES how many do you smoke each day?:

If NO when did you quit?:

There are plenty of options available to help you quit. Is this something you would like us to contact you about?: *