Adult Asthma Annual Review Questionnaire IMPORTANT – Please only do this questionnaire if you a registered patient at The Beeches Medical Centre, WidnesFirst Name Surname Date of Birth Contact Telephone NumberIMPORTANT – Please only do this questionnaire if you a registered patient at The Beeches Medical Centre, WidnesAddress Street Address City ZIP / Postal Code Current Health StatusIn this section we will ask you general questions about your current health.Please select one of the following with regards to your smoking status. Never Smoked Ex Smoker Light Smoker (1-9 cigarettes per day) Moderate Smoker (10-19 cigarettes per day) Heavy Smoker (20-39 cigarettes per day) Very Heavy Smoker (More than 40 cigarettes per day) User of Electronic Cigarette I do not wish to give this information If you currently smoke, are you interested in trying to quit or reduce your smoking? Yes – We will send you advice, information and contact details on the best ways and treatment to quit smoking Optional No – I do not want to stop smoking Optional Not Applicable Optional How many units of alcohol do you consume per day? I do not drink alcohol I only ever drink occasionally Light Drinker (1-2 units per day) Moderate Drinker (3-6 units per day) Heavy Drinker (7-9 units per day) I do not want to give this information What is your weight? Optional For example – 12st3 or 78kgHow tall are you? Optional For example – 6ft or 1.82mWhat is your blood pressure? Optional If you do not know your blood pressure reading, then please call into the surgery and use our free BP machine located in reception. This will also record your height and weight. No appointment is required. Please ask reception for a gold token to use the machineAsthma Control QuestionsIn this section we will ask you questions regarding your asthma control and management.How many asthma attacks have you had in the last 12 months How compliant are you with your inhaler or how would you rate your technique? Good Inhaler Technique Moderate Inhaler Technique Poor Inhaler Technique Good compliance with inhaler Poor compliance with inhaler During the past 4 weeks, how often did your asthma prevent you from getting as much done as possible at work, school or home? All of the time (1) Most of the time (2) Some of the time (3) A little of the time (4) None of the time (5) During the past 4 weeks, how often have you had shortness of breath? More than once a day (1) Once a day (2) 3 to 6 times a week (3) 1 to 2 times a week (4) Not at all (5) During the past 4 weeks, how often does your asthma symptoms wake you up during the night or early morning? 4 or more times a week (1) 2 to 3 times a week (2) One a week (3) Once or twice in the last 4 weeks (4) Not at all (5) During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? 3 or more times day (1) 1 to 2 times a day (2) 2 to 3 times a week (3) Once a week or less (4) Not at all (5) During the past 4 weeks, how would you rate your asthma control? Not controlled (1) Poorly controlled (2) Somewhat controlled (3) Well controlled (4) Completely controlled (5) Asthma ReviewThe last part of the questionnaire, will ask you if you feel your asthma is well controlled and will give you the option to decide if you would like further review from a Practice Nurse.Do you feel that asthma symptoms and management are well controlled at the moment? Well controlled – No review required. Not controlled – I need a review with a Practice Nurse
