Wareham Surgery

Streche Road, Wareham, BH20 4PG

Telephone: 01929 553444

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Asthma Questionnaire

Asthma Questionnaire

As part of your asthma care it is important that you have an annual review to assess the effectiveness of your treatment and any symptoms or problems that you may be having. Preferably this is done in our respiratory clinic and we would like to invite you to make an appointment, but if you cannot attend please complete and return this questionnaire to the surgery.
Name*
Date of Birth*
DD slash MM slash YYYY
Email*
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?*
- All of the time
- Most of the time
- Some of the time
- a little of the time
- None of the time
During the past 4 weeks, how often have you had either shortness of breath, wheeze, chest tightness during the day?*
- More than once a day
- Once a day
- 3-6 times a week
- 1-2 times a week
- not at all
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?*
- 4 or more times a week
- 2-3 nights a week
- Once a week
- once or twice
- not at all
During the past 4 weeks, how often have you used your blue inhaler (usually blue)?*
- 3 or more times a day
- 1-2 times a day
- 2-3 times a week
- once a week or less
- not at all
How would you rate your asthma control during the past 4 weeks?*
- Not controlled
- Poorly controlled
- Somewhat controlled
- Well controlled
- Completely controlled
Do you smoke?*
- Yes
- No (Ex-Smoker)
- No (Never Smoked)
What and how much?
When did you give up?
Smoking is the biggest cause of preventable deaths in England, accounting for more than 80,000 deaths each year. One in two smokers will die from a smoking-related disease.(https://www.nhs.uk/smokefree)

One year after stopping, the risk of a heart attack falls to about half that of a smoker. Within 15 years the risk falls to a level similar to that of a person who has never smoked. If smokers quit before the age of 30 they can avoid almost all of the risk of lung cancer attributable to smoking. (http://ash.org.uk/category/information-and-resources/fact-sheets)

If you would like help to stop smoking, please visit www.livewelldorset.co.uk or call 0800 840 1628 You will be offered advice and treatment in the form of nicotine replacement, or alternative medication which may improve your chances of successfully quitting.
Do you check your peak flow?*
- Yes
- No
What is your best reading and current reading?
Do you have any known asthma triggers (e.g. seasonal, cold, pollen, dust etc.)?*
The Respiratory Nurse will assess your responses and you may be contacted if there is cause for concern. In the meantime, if you have any concerns regarding your symptoms or treatment, please contact the surgery and ask to speak to the Respiratory Nurse.
Phone
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Youth Triage Form age 13-17

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Opening Times

Monday
08:30 until 13:00
14:00 until 18:30
Tuesday
08:30 until 13:00
14:00 until 18:30
Wednesday
08:30 until 13:00
14:00 until 18:30
Thursday
08:30 until 13:00
14:00 until 18:30
Friday
08:30 until 13:00
14:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

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Patient Participation Group

This is called a virtual PPG because we never have meetings! Members communicate by email. In that way they can keep up to date with news from the Purbeck Network and indeed the NHS as well as share ideas and questions
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