Asthma Review

This form is currently in development. Please do not complete it unless asked to do so.

Thank-you for taking the time to complete an online review of your asthma. Your answers will be reviewed and scored by a trained member of the Tyne Medical Practice team. After your form has been reviewed, you will receive a text message either confirming that the information provided is satisfactory or inviting you to make an appointment for a face-to-face review of your asthma. If you do not receive a text message within 4 weeks of completing your form or if you have any questions, please contact us on 01620 823183 to discuss further.

PLEASE NOTE: THE ANSWERS YOU PROVIDE ON THIS FORM WILL NOT AFFECT YOUR ABILITY TO OBTAIN PRESCRIPTIONS OF YOUR ASTHMA MEDICATION.

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Personal Details

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

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Asthma Control Score

(1) During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?: *

(2) During the past 4 weeks, how often have you had shortness of breath?: *

(3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?: *

(4) During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? : *

(5) How would you rate your asthma control during the past 4 weeks?: *

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Additional Questions

Please complete the additional questions below and then press submit to send your review to your Doctor.

How often do you use your preventative inhaler (if you have one)?: *

How confident are you with your inhaler technique: *

Do you have a peak flow meter?: *

Do you smoke?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Asthma Review

This form is currently in development. Please do not complete it unless asked to do so.

Additional Questions

Privacy Consent

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