Reception: Asthma & Medication Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are significantly deteriorating or you are having any concerns please make a telephone appointment with our Nurse.

You may have received a text or a letter. This is because asthma reviews are an essential way of monitoring your symptoms and ensuring your medication is safe and appropriate.

Asthma Information Zone

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 7 working days to complete. Please DO NOT call before 7 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations

Reception: Asthma & Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact number (preferably mobile)

Email Address

How often does your asthma cause symptoms during the day?

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

How often does your asthma cause symptoms at night?

During the past 4 weeks, how often have you had shortness of breath?

How would you rate your asthma control during the past 4 weeks?

How often does your asthma limit your activities?

On average, how many times a week do you need to use your reliever inhaler (Blue salbutamol/Ventolin inhaler)?

How many asthma exacerbations have you had in the past 12 months?An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.

How many asthma exacerbations have you had in the past 12 months?An exacerbation is where your symptoms got worse AND your reliever did NOT help and you needed to seek urgent medical attention

Smoking History

Is there anyone in your household who smokes?

Do you have any further information about your asthma that you feel is relevant to this review? Please note that your answer will not be seen immediately and you should direct any URGENT queries to reception.

Do you have an asthma care plan? If so when was it last reviewed?

Asthma Control Test

How would you rate your asthma control during the past 4 weeks?

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

During the past 4 weeks, how often have you had shortness of breath?

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?

Medication Review

Do you have any concerns or side effects from your medication?If No please write 'NO'. This is in relation to all your medication. Please state the medication and the side effect. E.g. Paracetamol: Constipation

Do you know how and when to take your medication?

Please record your most recent home/hospital/pharmacy blood pressure:

Are you on any antidepressant medication?

If you are on antidepressants, can you please select the option which best applies to you?

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

How many units of alcohol do you consume per week?

What is your current weight? (In Kg or Stones)

I confirm I am happy to be contacted by the surgery on the mobile number provided if deemed necessary

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Reception: Asthma & Medication Review

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