Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms, please use this form.

Before you complete the form, please download our Asthma Action Plan and watch the Asthma Inhaler Technique videos.

If your symptoms are deteriorating or you are having any concerns, please request an appointment with our asthma nurse.

Asthma Review

Asthma Review

Before you complete the form, please download our Asthma Action Plan and watch the Asthma Inhaler Technique videos.

Asthma Action Plan *
Please let us know that you have watched and understood the video(s): *

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Ethnicity

Please specify the ethnic group you consider you belong to: *

Are you under 19 years old? *
Have you ever been exposed to tobacco?
Are you exposed to tobacco smoke at home?
Are you exposed to second hand tobacco smoke?
Do you have a history of exposure to second hand smoke?