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.