Asthma Review

If you have been advised by the surgery that you need an annual review of your asthma symptoms you can submit your review using this form. Please note that ideally you should be seen in surgery at least every 3 years by the asthma nurse. However, if your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Swallowfield Asthma Review

Swallowfield Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
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 3 months, have you had difficulty sleeping because of your asthma symptoms (including cough)? *
During the past 3 months, has your asthma interfered with your usual activities (e.g. housework, work, school, etc.)? *
During the past 3 months, have you had your usual asthma symptoms during the day (wheezing, coughing, chest tightness, breathlessness)? *
Does your asthma affect you exercising? *
During the past 3 months, how often have you had shortness of breath? *
During the past 3 months, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 3 months? *
Have you had a face to face review with the asthma nurse in the last 3 years? *