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  • Contact Preferences
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Asthma Questionnaire

Please take this opportunity to update your doctor on the status of your asthma. The information supplied will be added to your medical record.

Should the doctor or nurse wish to speak to you about your current condition the practice will contact you.

All fields marked * are required.


Full Name: *
Date of birth: *

Day: Month: Year:

1. What inhalers do you use for your asthma?
a)
b)
c)
How often do you use each inhaler?
2. What is your best ever peak flow reading, if known? (l/min)
Do you have a peak flow meter for use at home? *
Yes No
If so, what is your peak flow reading today? (l/min)
3. Do you smoke? *
Yes No
If yes, how many per day?
Have you considered stopping?
Yes No
If you do not smoke, have you ever smoked?
Yes No

If you would like help and support to stop smoking, the surgery is pleased to offer this service. Please make an appointment with the Practice Nurse.

4. Over the last four weeks, have you experienced any of the following:

Difficulty sleeping at night due to asthma symptoms, such as shortness of breath, coughing or wheezing?
Yes No
Problems from your asthma symptoms during the day?
Yes No
Your asthma interfering with your normal daily activities?
Yes No
5. If you find it difficult to come to the surgery for your annual review, please tell us what day and time of day would suit you:
 

Thank you very much for taking the time to complete this form.

If you have any non-urgent questions about your asthma or current conditions you can contact the surgery by email (via the online Enquiry Form) or telephone.

Please complete or update the online Contact Preferences Form if you have not already done so.

The Christmas Maltings and Clements Practice - Telephone: 0844 477 3543  
Practice Locations: Christmas Maltings Surgery - Camps Road, Haverhill, CB9 8HF Clements Surgery - Greenfields Way, Haverhill, CB9 8LU Kedington Surgery - 36 School Road, Kedington, CB9 7NG
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