Asthma Review Form - Bangholm Medical Centre

Name *

Date of Birth *

During the last 4 weeks, how often has your asthma restricted you from carrying out activities at work/school/home? *

(1) All of the time

(2) Most of the time

(3) Some of the time

(4) Very rarely

(5) None of the time

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

(1) More than once per day

(2) Once per day

(3) 3-6 times per week

(4) 1-2 times per week

(5) Not at all

During the last 4 weeks, how often has your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness/pain) disturbed your sleep? *

(1) 4+ times per week

(2) 2-3 times per week

(3) 1-2 times per week

(4) Once per week

(5) Not at all

During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as salbutamol)? *

(1) 3+ times per day

(2) 1-2 times per day

(3) 2-3 times per week

(4) Once per week or less

(5) Not at all

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

(1) Not controlled

(2) Poorly controlled

(3) Somewhat controlled

(4) Well controlled

(5) Completely controlled

What is your score? (Add up each of your five scores to get your total asthma control score) *

20-25 - On target. Your asthma appears to have been under control over the last 4 weeks. However, if you are experiencing any problems with your asthma, please make an appointment.

16-19 - Off target. Your asthma symptoms may not be as well controlled as they could be. There may be more you or our clinicians could do to help control your asthma symptoms. Please make an appointment.

<15 - Off target. Your asthma has not been controlled during the past 4 weeks. Please make an appointment straight away.

Asthma Review Form.

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Asthma Review Form.

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