Bushloe Surgery - Asthma submission form

Title:

First Name(s):

Surname:

Email:

Postcode:

Preferred Contact Number:

Date of Birth:

Q1) How many Exacerbations of Asthma have you had in the last 12 months:

Q2) Smoking Status:

Q3) In the last 4 weeks Have you had shortness of breath?

Q4) In the last 4 weeks Have you used your reliever inhaler (usually blue)?

Q5) How would you Rate your Inhaler Technique:

Q6) In the last 4 weeks Did your asthma prevent you from getting as much done at work/school/home?

Q7) In the last 4 weeks Did your asthma symptoms wake you up at night or early in the morning?

Q8) How would you rate your asthma control?

Please click the green button below to submit your answers to the surgery Thank you