Asthma Review Form RMP

Asthma Review Form RMP

Please only complete the following questionnaire if requested by your GP practice as part of your routine asthma review.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Asthma review

  • Inhaler Technique

    It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly. 

    Asthma UK Inhaler videos https://www.asthmaandlung.org.uk/living-with/inhaler-videos

    I have watched the above relevant inhaler technique video and am happy with my inhaler technique

  • Lifestyle - Smoking

    Do you smoke?
    Do you use an e-cigarette or vape?
    If you do smoke, would you like help to quit smoking? (For further information, please see www.nhs.uk/smokefree (optional)

  • Asthma Control Score

    The asthma control test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled. If you are 12 years or older, please complete the questions below. 

    Once you have completed the test, please calculate your score to work out what your score is and what it means. 

    How often did your asthma prevent you from getting as much done at work, school or home?
    How often have you had shortness of breath?
    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?
    How often have you used your reliever inhaler (usually blue)?
    How would you rate your asthma control during the past 4 weeks?
    If your score is 25 or more - Your asthma is well controlled
    If your score is 20 to 24 - Your asthma is reasonably well controlled
    I f your score is 19 or less - your asthma is not well controlled

  • Further questions and consent

    When you have completed the form please click submit below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and you other medical conditions you will be contacted if you need to be seen in clinic for further assessment. Should you symptoms change, please seek medical advice and book an appointment if required.

    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.
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Page last reviewed: 17 July 2023
Page created: 23 August 2022