Willowbrook Medical Practice

Brook Street, Sutton in Ashfield, Nottinghamshire, NG17 1ES

Telephone: 01623 440018

nnicb-nn.c84012@nhs.net

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Asthma Review Questionnaire

Asthma Review Questionnaire

We are using this secure online consultation to help review your asthma. Once we have assessed your answers you may be able to complete your review without a face-to-face appointment. You can also access some relevant health information.
OPTIONAL: You can submit your recent peak flow reading, weight and height
Please only complete the following questionnaire if requested by your GP practice as part of your routine asthma review.

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.
If text is too small on your device, turn it sideways. You can also type the link you received into a tablet or computer browser to view on a larger screen
To use this Online Consultation you must confirm the following. If you are unable to do so please contact the practice.*
- I am currently located in the United Kingdom
- I am a registered patient at Willowbrook Medical Practice
- I consent to the use of this Online Consultation in accordance with our privacy notice (https://willowbrookmp.co.uk/about-us/general-practice-privacy-notice/)
I confirm the above is true & correct
Name*
Title First Name Last Name
Date of Birth*
DD slash MM slash YYYY
Age in years*
NHS Number (if known)
Optional
Phone number
Your email address
You don't have to provide this information but if you do, you can change your mind at any time. Just contact us.
Enter Email Confirm Email
Consent*
Your email address will only be used for the purposes of providing you with healthcare information and will not be passed on to anyone outside of the organisation.

If you do not agree to this please remove your email address from this form.

I agree the email address provided can be added to my medical record.
Optional Questions
How do you want to enter your weight?*
Stones*
Pounds*
Please enter your weight to the nearest pound*
Please enter your weight to the nearest kilogram*
Hidden
HIDDEN - OLD FIELD DO NOT DELETE -
Please specify whether stones & pounds or kilograms
How would you like to enter your height?*
Please select your height to the nearest inch*
Please enter your height to the nearest centimetre*
If you have a peak flow meter please enter a recent reading
BP
Do you have a home Blood Pressure machine?*
- Yes
- No
Please enter your most recent reading below.
Systolic*
(upper reading)
Diastolic*
(lower reading)
Asthma Review
How often does your asthma cause symptoms during the day?*
- Never
- 1 to 2 times per month
- 1 to 2 times per week
- Most days
How often does your asthma cause symptoms at night?*
- Never
- 1 to 2 times per month
- 1 to 2 times per week
- Most nights
How often does your asthma limit your activities?*
- Never
- 1 to 2 times per month
- 1 to 2 times per week
- Most days
How many asthma exacerbations (attacks) have you had in the past year?*
Enter 0 if none
How many times have you attended Accident and Emergency Department since your last asthma review?*
Enter 0 if none
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.
• Asthma UK Inhaler Videos (opens in new tab/window)
I have watched the above relevant inhaler technique videos and am happy with my inhaler technique*
- Yes
- No
Lifestyle - Alcohol
How often do you have a drink containing alcohol?*
- Never
- Monthly or less
- 2-4 times a month
- 2-3 times a week
- 4 times or more a week
How many units of alcohol do you drink on a typical day drinking?*
- 0
- 1-2
- 3-4
- 5-6
- 7-9
- 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
- Never
- Less than monthly
- Monthly
- Weekly
- Daily or almost daily
Lifestyle - Smoking
Do you smoke?*
- Never
- Ex-smoker
- Trivial smoker (less than 1 cigarette per day)
- Light smoker (1-9 cigarettes per day)
- Moderate smoker (10-19 cigarettes per day)
- Heavy smoker (20-39 cigarettes per day)
- Very heavy smoker (40 or more cigarettes per day)
Do you use an e-cigarette?*
- No
- Ex-User
- Yes
If you smoke, would you like help to quit smoking?*
For further information, please see:
NHS Smokefree (opens in new tab/page)
- Yes
- No
Do any members of your household smoke?*
- Yes
- No
Further Questions
I have the following information, questions or concerns that I would like to raise with my Asthma Nurse or Doctor:
Optional
Please see the following links for further information on asthma that you may find useful (links will open in new tab/page):

- NHS Asthma

- Patient.info

- Asthma 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.
Hidden
HIDDEN FIELD * DO NOT DELETE * Are you 12 years or older?
(are you over 12 years of age?)
- Yes
- No
Asthma Control Test
a) How often did your asthma prevent you from getting as much done at work / school / home?*
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
a) Score
b) How often have you had shortness of breath?*
- More than once a day
- Once a day
- 3-6 times a week
- 1-2 times a week
- None at all
b) Score
c) How often did your asthma symptoms wake you up at night or early in the morning?*
- 4 or more times a week
- 2-3 nights a week
- Once a week
- Once or twice
- Not at all
c) Score*
d) How often have you used your reliever inhaler (usually blue)?*
- 3 or more times a day
- 1-2 times a day
- 2-3 times a week
- Once a week or less
- Not at all
d) Score
e) How would you rate your asthma control?*
- Not controlled
- Poorly controlled
- Somewhat controlled
- Well controlled
- Completely controlled
e) Score
What your score means

• If your score is 25 - Your asthma is well controlled

• If your score is 20 to 24 - Your asthma is reasonably well controlled

• If your score is 19 or less - Your asthma is not well controlled
Asthma Control Test Score
Feedback
Would you recommend this online system to your family and friends?
- Yes
- No
Asthma review submission
When you are happy with all your above answers, please click Submit below and the questionnaire will be automatically sent to Willowbrook Medical 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.
Name
This field is for validation purposes and should be left unchanged.

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Monday
08:00am to 06:30pm
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Friday
08:00am to 06:30pm
Lines closed 12:30 to 1:30pm
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Extended Hours available on request
Sunday
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Extended Hours available on request

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