Asthma Questionnaire

Please select the practice location most relevant to this Online Form submission:

Full Name

Date of Birth

Contact Telephone Number

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?

During the past 4 weeks, how often have you had shortness of breath?

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?

During the past 4 weeks, how often have you used your preventer inhaler (usually the brown, purple, red or orange inhaler)?

How would you rate your asthma control during the past 4 weeks?

How many asthma flare ups (exacerbations) have you had in the past 12 months?An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention

Do you have any further information about your asthma that you feel is relevant to this review?Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery

What is your smoking status?

How much do you smoke? (if answered Current smoker to the previous question)

Does anyone else in your household smoke? (if the patient is 19 years old or younger)

Who smokes in your household? (if the patient is 19 years old or younger)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Gervis Road Surgery • 14 Gervis Road , Bournemouth , BH1 3EG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services

Residential/
Nursing Care

Wills
& LPA

Residential/
Nursing Care Jobs

Domiciliary
Care Agency