Your Name (required)
Date of Birth (required)
Q.1 When was your asthma diagnosed?
Please select...Less than 5 years agoMore than 5 years agoMore than 10 years ago
Q.2 In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?
Please select...NoYes, every dayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a yearYes, see details below
Q.3 In the last month, have you had your usual asthma symptons during the day? (cough, wheezing, chest tightness or breathlessness)
Please select...NoYes, every dayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a yearYes, see below for details
Q.4 How often do you use your blue inhaler?
Please select...DailyWeeklyMonthyAnnualOther, see below for details
Q.5 In the last month has your asthma interfered with your usual activities (e.g.housework, work, school etc?
Q.6 Have you ever had your peak flow measured at the surgery?
If 'Yes' do you know your best PEFR value
Q.7 Are you happy with your inhaler technique?
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.
Q.8 Have you ever smoked?
If 'Yes' please answer the following:
Do you smoke now?
If 'Yes' how many do you smoke each day?
If 'No', when did you quit?
There are plenty of options available to help you quit. Is this something you would like us to contact you about?