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Asthma submission form
Bushloe Surgery -
Asthma submission
form
Please leave blank:
Title:
---Please select---
Mr
Mrs
Miss
Ms
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:
Please Select
Never Smoked Tobacco
Ex-Smoker
Cigarette Smoker
Q3) In the last 4 weeks Have you had shortness of breath?
Please Select
More than once a day
Once a day
3-6 times a week
1-2 times a week
None at all
Q4) In the last 4 weeks Have you used your reliever inhaler (usually blue)?
Please Select
3 or more times a week
1-2 times a week
2-3 times a week
Once a week or less
Not at all
Q5) How would you Rate your Inhaler Technique:
Please Select
Good
Moderate
Poor
Q6) In the last 4 weeks Did your asthma prevent you from getting as much done at work/school/home?
Please Select
All of the time
Most of the time
Some of the time
A little of the time
None of the time
Q7) In the last 4 weeks Did your asthma symptoms wake you up at night or early in the morning?
Please select
4 or more times a week
2-3 times a week
Once a week
Once or twice
Not at all
Q8) How would you rate your asthma control?
Please Select
Not controlled
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
Please click the green button below to submit your answers to the surgery
Thank you
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