College Way Surgery

ANNUAL ASTHMA QUESTIONNAIRE

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TitleFull NameDate of BirthNHS Number

Asthma Health Review

1. During the past 4 weeks, how often did your asthma limit your activities at home or work?2. During the past 4 weeks, how often have you had daytime asthma symptoms (wheezing, coughing, chest tightness,shortness of breath)?3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?4. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?5. How would you rate your asthma control during the past 4 weeks?6. Have you ever smoked? (Please tick)Stopping smoking is the single most important thing you can do to improve your health. If you would like help to stop smoking please contact: Somerset NHS Stop Smoking Service on 0303 033 9840.

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