Asthma Review

Asthma Review

Please complete this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required

About Your Asthma

Do you have asthma?  Required
How often does your asthma cause symptoms during the day?  Required
How often does your asthma cause symptoms at night?  Required
How often does asthma limit your activities?  Required
An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.
Please note that your answers will not be seen immediately and you should direct any urgent queries to your GP surgery
What is your smoking status?  Required
How much do you smoke?  OptionalPlease answer this section if you answered 'Current Smoker' for the above question.
Does anyone else in your household smoke?  RequiredIf patient is 19 years old or younger.
If patient is 19 years old or younger.
Privacy Protection  Required

 

Additional Information

Carers

Chaperoning

GDPR, Data Processing and Subject Access Request (SAR)

Infection Control

Long Term Conditions

Summary Care Records

Zero Tolerance Policy

Non-NHS Services

Patient Participation Group

Responsibilities

Talking Saves Lives

Winter Health

Community and Locality Services

Complaints Policy