Asthma Questionnaire

Name*

Date of Birth*

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? Optional

When did you give up? Optional

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? Optional

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.

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Email Optional

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Asthma Questionnaire

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