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Adult Asthma Review

Please complete the form below to calculate your Asthma control

Name: *
Email: *
Date of Birth(DD-MM-YYYY): *
Phone:
Which Surgery are you registered at?

During the past 4 weeks, how often did your asthma prevent 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, chest tightness, shortness) wake up you at night or earlier than usual in the morning?

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

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