Asthma Annual Assessment Asthma Annual Assessment Full Name * Date of Birth * Address * Phone Number * Email Address * Smoker Status * Non-smoker Current Smoker Ex-smoker Number of years smoking * How many per day? * Number of years you were a smoker * How many per day? * In the last year: Have you had difficulty sleeping because of your asthma symptoms (including cough), or wake up needing the blue inhaler? * Yes No How many times? * Everyday 1-2 times a month 1-2 times a month More than 2 times a month Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness? * Yes No How many times? * Everyday 1-2 times a week 1-2 times a month More than 2 times a month Has your asthma interfered with your usual daily activities e.g. housework, work/school etc. * Yes No Do you need to use your inhaler e.g. salbutamol etc. more than 1-2 times a week? Please state if used for exercise * Yes No Please state if used for exercise Are you happy with your inhaler technique? * Yes No Don’t forget your FREE flu vaccination (please note you are only eligible if you regularly take a steroid inhaler/tablet or been admitted to hospital in the past due to exacerbations). If you are eligible but do not wish to be vaccinated please tick the following box I do not wish to be vaccinated For more information on asthma please visit the Asthma UK website or pop in and see our practice respiratory nurse for more advice. reCAPTCHA Submit
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