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Asthma Review

For patients who are due an annual asthma review.

 

Please would you answer the questions on the form below and submit it to us.

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If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well.

Asthma Annual Review Questionnaire

Please answer the questions in this short questionnaire to enable us to assess your alcohol consumption rate and offer advice if necessary.

Patient Details
Questionnaire
In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?
Have you ever had your peak flow measured at the surgery?
Are you happy with your inhaler technique?
Have you ever smoked?
Do you smoke now?
There are plenty of options available to help you quit. Is this something you would like us to contact you about?
Asthma Control Score
Do you agree to our terms and conditions?

Thank you . Your answers have been submitted to our team.

Note that by using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your comment.

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Your IP address will be sent with your communication. In rare cases where abuse or criminal activity can be shown to have taken place this may be used by the authorities to trace you.

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