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ANNUAL ASTHMA QUESTIONNAIRE

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Personal Details

Title Full Name Date of Birth NHS 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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