Asthma Pre-assessment questionnaire

Asthma Pre-assessment questionnaire

  • Patient Details

    Date of Birth
    For example, 15 3 1984

  • This questionnaire is for a routine review of your symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

    Pre-assessment questionnaire

    How often does your asthma cause symptoms during the day?
    How often does your asthma cause symptoms at night?
    How often does your asthma limit your activities?

  • Exacerbations

    How many asthma exacerbations (attacks) have you had in the past year?
    How many times have you attended Accident and Emergency Department since your last 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: Copy the link in a new web browser: Asthma UK Inhaler Videos: https://www.asthma.org.uk/advice/inhaler-videos/

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

  • Lifestyle – Alcohol

    (XaORP)

    How often do you have a drink containing alcohol?
    How many units of alcohol do you drink on a typical day drinking? Please see: https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator
    How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

  • Lifestyle – Smoking

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

  • Further Questions

  • Useful links

    Please see the following links for further information on asthma that you may find useful: NHS - http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx Patient.Info - http://patient.info/health/asthma-leaflet Asthma UK - https://www.asthma.org.uk

  • Asthma Control Test 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.

    Asthma Control Test Score - Please click 'Calculate Score' by adding the numbers at the end of your answers to work out your score and what it means.

  • When you are happy with all your above answers, please click 'Submit' below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

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Page last reviewed: 30 June 2021
Page created: 04 January 2024