Asthma Review Form

Please complete this form prior to your annual asthma review with our practice nurse.

Last Updated: 22/09/2024

Your Details

Name *

Date of Birth *

Phone Number

Email Address

Asthma Control Score

Asthma Review

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Yes No

Since your last review, have you needed a course of steroid tablets to get your asthma under control?

Yes No

Do you smoke?

Yes No

Did you have winter vaccinations last season?

Yes No

Consent

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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Asthma Review Form

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