Asthma Review Questionnaire Full name*Your date of birth*How often do you use your blue inhaler? (either: Ventolin, Salbutamol or Terbutaline)*Never1-2 times per month2-3 times per weekMore than 2-3 times per weekDoes your asthma cause any day-time symptoms?*Asthma never causes daytime symptomsAsthma causes daytime symptoms 1 to 2 times per monthAsthma causes daytime symptoms 1 to 2 times per weekAsthma causes daytime symptoms most daysDoes your asthma cause any night time symptoms?*Asthma never causes night time symptomsAsthma causes night time symptoms 1 to 2 times per monthAsthma causes night time symptoms 1 to 2 times per weekAsthma causes symptoms most nightsDo you experience asthma symptoms when you carry out activities?*Asthma does not limit activitiesAsthma limits activities 1 to 2 times per monthAsthma limits activities 1 to times per weekAsthma limits activities most daysDo you experience asthma symptoms when you exercise?*YesNoHow many times a week do you exercise?*OnceTwiceThree timesFour timesFive timesSix timesSeven timesDo you use your reliever (blue) inhaler prior to exercise?*YesNoPlease provide a brief description as to what triggers your asthma symptoms*Have you been admitted to hospital in the past 12 months as a result of your asthma?*YesNoHave you required a course of oral steroids for your asthma in the past 12 months?*YesNoHas your doctor changed your asthma medication in the past year to improve your asthma symptoms?*YesNoDo you have a brown inhaler (preventer)*YesNoIf you have a brown inhaler do you use this every day even when you don't experience any asthma symptoms?YesNoPlease record your smoking status:*Never SmokedEx-SmokerSmokerCigarette Smoker - please state amount per dayCigar Smoker - please state amount per dayPipe Smoker - please state grams smoked per dayIf you have you are a smoker wish to quit and would like support to help you quit then please contact the Surgery to make an appointment with a Practice Nurse or contact: https://www.livewelldorset.co.uk/stopsmoking If you have answered 'YES' to any of the above questions, we strongly advise that you book an appointment for an asthma review at your earliest convenience with either Valerie or Abby our practice nurses. Once you have submitted your completed questionnaire our Practice Nurses will assess your responses and ask you to attend for a review if they have any concerns. Even mild asthma or poorly treated asthma symptoms can cause chest problems in the future, so it is important that we ensure your asthma medication if you are taking any is being administered appropriately and correctly. Please copy the link below to refresh/update your inhaler technique and also to obtain other aspects of asthma support. asthma.org This iframe contains the logic required to handle Ajax powered Gravity Forms.