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The Barcellos Family Practice

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Glenmoor Rd 01202 874302
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About Us
Clinics and Services
Appointments
Prescriptions
Contact and Location
Opening Hours
Online Services
Carers Support
Patient Participation Group
Test Results
New Patient Registration
Update Your Details

Home
Clinics and Services
Appointments
Prescriptions
Do it Online
Corbin Ave 01202 897989
Glenmoor Rd 01202 874302
News

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The Barcellos Family Practice Asthma Review Form

The Barcellos Family Practice Asthma Review Form

The Barcellos Family Practice Asthma Review Form

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.

Before your appointment, please watch a short video to learn how to use your inhaler properly and better manage your respiratory symptoms. Follow this link and select the video appropriate to the device you use>>

Your Details

Patient's full Name *

Patient's Date of Birth (DD/MM/YYYY) *

Email Address *

Mobile Phone Number

Landline Phone Number

Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?

Yes No

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?

Yes No

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?

Yes No

How often do you need to use your reliever inhaler?

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes No

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes No

Do you smoke?

Yes No

Did you have a flu vaccination last flu season?

Yes No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?)

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? *

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5

Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 12 June 2023
Page created: 26 April 2023

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