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    Questionnaire

    Q.1 When was your asthma diagnosed?

    Q.2 In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

    Q.3 In the last month, have you had your usual asthma symptons during the day? (cough, wheezing, chest tightness or breathlessness)

    Q.4 How often do you use your blue inhaler?

    Q.5 In the last month has your asthma interfered with your usual activities (e.g.housework, work, school etc?

    NoYes

    Q.6 Have you ever had your peak flow measured at the surgery?

    NoYes

    If 'Yes' do you know your best PEFR value

    ml/min

    Q.7 Are you happy with your inhaler technique?

    NoYes

    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?

    NoYes

    If 'Yes' please answer the following:

    Do you smoke now?

    NoYes

    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?

    NoYes

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