What is your date of birth?*

For example, 15 3 1984

Day

Month

Year

What is your name?

What is your first name(s)?*

What is your surname?*

Contact Information

What is your mobile number?

What is your home phone number?

What is your email?*

What is your address?*

Building and street

Town or city

County

Postcode

Smoking status

Are you aged over 14 and over?*

Yes

No

Smoking status*

Never smoked tobacco

Ex-smoker

Current smoker

How many per day?*

Do you want to quit smoking? Please visit https://www.nhs.uk/smokefree for more information or contact the surgery.

How long have you stopped?*

Are you aged 19 and under?*

Yes

No

Have you been exposed to cigarette/tobacco smoke at home in the past 12 months?

Yes

No

In the past 4 weeks:

During the last 4 weeks, did your asthma prevent you from getting as much done at work, school or home?*

All the time (1 point)

Most of the time (2 points)

Some of the time (3 points)

A little of the time (4 points)

None of the time (5 points)

Score = fields.ashtmaAtWorkSchool

During the last 4 weeks, have you had shortness of breath?*

More than once a day (1 point)

Once a day (2 points)

3- 6 times a week (3 points)

1 – 2 times a week (4 points)

Not at all (5 Points)

Score = fields.shortnessOfBreath

During the last 4 weeks, did our asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?*

More than once a day (1 point)

Once a day (2 points)

3- 6 times a week (3 points)

1 – 2 times a week (4 points)

Not at all (5 Points)

Score = fields.asthmaSleepingSymptoms

During the last 4 weeks, have you used your reliever inhaler?*

This usually your blue inhaler.

3 or more times a day (1 point)

1 – 2 times a day (2 points)

2 – 3 times a week (3 points)

Once a week or less (4 points)

Not at all (5 Points)

Score = fields.relieverInhalerUsage

How would you rate your asthma control during the last 4 weeks?*

Not controlled (1 points)

Poorly controlled (2 points)

Somewhat controlled (3 points)

Well controlled (4 points)

Completely controlled (5 points)

Score = fields.asthmaControl

How many asthma exacerbations have you had in the last year?

Number of exacerbations

Are you happy with your inhaler technique?*

Yes

No

Your result

You scored fields.result

Your asthma is well controlled. If however you are experiencing any problems with your asthma you should contact the surgery.

You scored fields.result

Your asthma appears reasonably well controlled. If however you are experiencing any problems with your asthma you should contact the surgery.

You scored fields.result

Your asthma is not well controlled. Please book an asthma review with the Specialist Nurse.

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly:

Asthma UK Inhaler Videos - http://www.asthma.org.uk/advice/inhaler-videos/

For more information on asthma please visit the Asthma UK website.

Concord Medical Centre

Online asthma questionnaire

What is your date of birth?*

What is your name?

Contact Information

What is your address?*

Smoking status

Are you aged over 14 and over?*

Smoking status*

Are you aged 19 and under?*

Have you been exposed to cigarette/tobacco smoke at home in the past 12 months?

In the past 4 weeks:

During the last 4 weeks, did your asthma prevent you from getting as much done at work, school or home?*

Score = fields.ashtmaAtWorkSchool

During the last 4 weeks, have you had shortness of breath?*

Score = fields.shortnessOfBreath

During the last 4 weeks, did our asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?*

Score = fields.asthmaSleepingSymptoms

During the last 4 weeks, have you used your reliever inhaler?*

Score = fields.relieverInhalerUsage

How would you rate your asthma control during the last 4 weeks?*

Score = fields.asthmaControl

How many asthma exacerbations have you had in the last year?

Are you happy with your inhaler technique?*

Your result

You scored fields.result

You scored fields.result

You scored fields.result