Thank you for taking the time to fill in this simple questionnaire about how your asthma is affecting you.

You have been asked to complete this form because it is some time since we last saw you for an asthma check. Your answers will help us to make sure that your asthma is as well controlled as possible.

Asthma Questionnaire

Title
MrMrsMissOther

Your Name (required)

Date of birth DD/MM/YY

Gender
MaleFemale

Your Email (required)

Your Address

Home phone (including area code)

Mobile phone

Work phone (including area code)

Questions

To help us to know more about your asthma, please complete the following questionnaire and click "send" at the bottom of this page.

1. Daytime symptoms

Do you have problems with asthma most days?
YesNo

2. Disturbed Sleep

Are you disturbed at night by your asthma?
YesNo

3. Limit Daily Activities

Does your asthma limit daily activities?
YesNo

If you have answered "Yes" to questions 1-3 above, your asthma may not be as well controlled as it could be and you should be reviewed. Would you like to discuss your asthma treatment?
YesNo

Do you smoke? (Ages 13 and Over)
YesNo

If "Yes how many per day?

Would you like an annual Flu Vaccination?
YesNo

Please click on send below and this information will be updated in your medical record.