Asthma Review Form For Practice Nurse

Asthma Review Form For Practice Nurse

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment with the practice nurse.

Information - 

Please see this website for information about inhaler technique

Using your inhalers | Asthma + Lung UK

NHS help to stop smoking is available via Quit Your Way. Please call 0131 537 9914 to arrange support and discuss options for help. 

 

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Asthma Review

    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 did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?
    During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
    How would you rate your asthma control during the past 4 weeks? Well controlled asthma means you have no daytime symptoms, no night-time waking due to asthma, no need for rescue medicine, no asthma attacks, asthma does not limit your activity and you are experiencing minimal side effects from treatment. If your symptoms have been very well controlled for over 3 months, it may be appropriate to reduce your regular inhaler. If this is the case, please arrange an appointment to discuss this with the practice nurse.

  • Consent

    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA
    By using Our site, you consent to such processing and you warrant that all data provided by you is accurate. Your registered e-mail address will be used by Newbyres Medical Group GP practice to send reminders and notifications. If you are sharing an e-mail address, those reminders and notifications will be viewable by any user of that shared e-mail address.
    Do you consent to being contacted by text and E Mail by the surgery? If No Please request a paper copy of this form and do not submit.
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Page last reviewed: 03 July 2025