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Holmhead Medical Practice

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Personalised Habit Coaching - (Holly Health)
Covid-19 Information
Know Who To Turn To
Appointment Information
Prescription Request
Fit Notes & Self Certifications
Clinics & Services
New Patients
Health Advice

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Asthma Questionnaire

DISCLAIMER: This form will be reviewed by the Practice Nurse within 2 to 4 weeks after completion and submission. If you feel that you are having symptoms regarding your asthma, please contact the surgery to make an appointment.

When you have filled out this questionnaire, please add up your score. See below for details:

Score 25 - Well controlled
Score 20-24 - Reasonably well controlled
Score less than 20 - Not well controlled. If your score is less than 20, please make an appointment with the Practice Nurse.

Last Updated: 19/11/2024

Personal Details

Patients Name *

Patients Date of Birth (DD/MM/YYYY) *

Patients Address *

Patients telephone number *

Asthma Control Test

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

All of the time - Score 1

Most of the time - Score 2

Some of the time - Score 3

A little of the time - Score 4

None of the time - Score 5

During the last 4 weeks how often have you had asthma symptoms during the DAY? (cough, wheeze, chest tightness or breathlessness) *

More than once a day - Score 1

Once a day - Score 2

3-6 times a week - Score 3

1-2 times a week - Score 4

Not at all - Score 5

During the last 4 weeks how often did your asthma symptoms wake you at night or earlier than usual in the morning? (cough, wheeze, chest tightness or breathlessness) *

More than once a day - Score 1

Once a day - Score 2

3-6 times a week - Score 3

1-2 times a week - Score 4

Not at all - Score 5

During the past 4 weeks how often have you used you reliever? (BLUE INHALER) *

3 or more times a day - Score 1

1-2 times a day - Score 2

2-3 times a week - Score 3

Once a week or less - Score 4

Not at all - Score 5

How would you rate your asthma control over the last 4 weeks? *

Not controlled - Score 1

Poorly controlled - Score 2

Somewhat controlled - Score 3

Well controlled - Score 4

Completely controlled - Score 5

If you have a preventer inhaler, how often do you use it? (e.g. one puff twice a day)

Do you know how to increase or decrease your inhalers if your asthma symptoms change and recognise when to contact the surgery for advice? *

Yes No

Smoking Status *

Current Smoker

Ex-smoker

Never Smoked

Smoking Advice

Smoking can not only trigger asthma symptoms but the lungs of smoker do not work as well as non-smokers.

Passive smoking can increase the likelihood of your child developing asthma and increased symtpms in children with asthma.

The surgery can offer advice and support to patients who wish to stop smoking.

Comments

If you have any comments about your asthma, please indicate them below:

What is your score from the questions above? Remember if this is less than 20, please make appointment with the Practice Nurse. *

Score 25

Score 20-24

Score less than 20 - Please make an appointment with Practice Nurse

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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