Asthma Annual Review Questionnaire

If you suffer from Asthma please complete this questionnaire once a year.

Demographics
Name*
First Last
Date of Birth*
Phone*
Email*
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Asthma Review
1. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?*
Details of sleeping difficulties (if applicable):
2. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?*
Details of symptoms during the day (if applicable):
3. How often do you use your blue inhaler?*
Details of inhaler use:
4. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?*
- Yes
- No
5. Are you happy with your inhaler technique?*
- Yes
- No
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.
Inhaler Technique Website
6. Have you ever smoked?*
- Yes
- No
If 'Yes' please answer the following: Do you smoke now?
- Yes
- No
If 'Yes', how many do you smoke each day?
Please enter a number from 1 to 999.
If 'No', when did you quit?
If exact day is unknown, please put the first of the month. If exact month is unknown, please put January.
There are plenty of options available to help you quit smoking. These are just a few.
Help to Stop Smoking
One You Leeds

Demographics