Asthma Pre-assessment questionnaire

Last Updated: 30/06/2021

Patient Details

First Name *

Surname *

Date of Birth *

Address *

This questionnaire is for a routine review of your symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Pre-assessment questionnaire

Exacerbations

Inhaler Technique

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: Copy the link in a new web browser: Asthma UK Inhaler Videos: https://www.asthma.org.uk/advice/inhaler-videos/

have watched the above relevant inhaler technique videos and am happy with my inhaler technique *

Yes (XaX3s)

Lifestyle – Alcohol

(XaORP)

Lifestyle – Smoking

Further Questions

I have the following questions that I would like to raise with my Asthma Nurse or Doctor:

Useful links

Please see the following links for further information on asthma that you may find useful: NHS - http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx Patient.Info - http://patient.info/health/asthma-leaflet Asthma UK - https://www.asthma.org.uk

Asthma Control Test Score

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled. If you are 12 years or older, please complete the questions below.

How often did your asthma prevent you from getting as much done at work/school/home? All of the time *

How often have you had shortness of breath? *

How often did your asthma symptoms wake you up at night or early in the morning? *

How often have you used your reliever inhaler (usually blue)? *

How would you rate your asthma control? *

Asthma Control Test Score - Please click 'Calculate Score' by adding the numbers at the end of your answers to work out your score and what it means. *

If your score is 25 or more - Your asthma is well controlled (XaQHq)

If your score is 20 to 24 - Your asthma is reasonably well controlled (XaQHq)

If your score is 19 or less - Your asthma is not well controlled (XaQHq)

When you are happy with all your above answers, please click 'Submit' below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

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Asthma Pre-assessment questionnaire

Further Information