Asthma Review Form - Stone Cross Surgery

Do you smoke? *

I have never smoked

I am an Ex-smoker

I am a current smoker

Do you believe you have good control of your Asthma? *

Yes No

Do you have any problems with your Asthma at night (such as cough or wheeze)? *

My Asthma is fine at night

I get a cough 2-3 x a week at night

I get a cough more than 3 x week at night

Does your Asthma affect you doing day to day things (such as cough or wheeze)? *

My Asthma does not stop me doing things

My Asthma interferes with me doing things.(ie I cough or wheeze when doing it)

My Asthma stops me doing things.

Does your Asthma stop you doing exercise? *

My Asthma does not stop me exercising.

My Asthma interferes with me exercising.(ie I cough or wheeze when doing it)

My Asthma stops me exercising.

Any other comments

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 *

I consent to the practice collecting and storing my data from this form.

Stone Cross Asthma Review

Further Information