Asthma Review Form

This form is to be used as a pre-check for your routine asthma review, to decide if you need further assessment.

If you feel that you need urgent medical attention for your asthma or need medication urgently, please submit the form and contact the surgery in the normal way. If you need urgent medical attention when the surgery is closed, please ring 111.

If you need to re-check your inhaler technique, please see www.asthma.org.uk/advice/inhaler-videos
If you need advice on what to do if you have an asthma attack, please see www.nhs.uk/conditions/asthma/asthma-attack
Please see www.asthma.org.uk/peak-flow for information on peak flow meters

Your Details

Are you completing this review for someone else ie. a child under 16?

Yes

Are you completing this review for a child aged 4-11?

Yes

Your First Name

Your Last Name

Relationship to the patient

Patient First Name *

Patient Last Name *

Email for us to contact you *

Phone Number for us to contact you *

Patient Date of birth *

Please use format day/month/year e.g. 12/05/1979

Privacy Policy

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.

If you are human, leave this field blank.

Asthma Review Form

Your Details

Adult Asthma Control Test

Child Asthma Control Test – Child to Answer

Child Asthma Control Test – Parent/Guardian to Answer

Additional Questions

Inhaler Technique

Asthma Review

Privacy Policy

Health A-Z

Live Well

Medicines Guide

Care & Support