Provide Asthma Screening

* = Information must be provided

Name *

Date of Birth *

Postcode *

In the last month have you had difficulty sleeping due to your asthma (including cough)? *

Yes

Times per week *

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *

Yes

Times per week *

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *

Yes

Times per week *

In the past 4 weeks, how often did your asthma keep you from getting as much done at work, school or at 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 – 6 times a week - 3

Once or twice a week - 4

Not at all - 5

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

4 or more nights a week - 1

2 or more nights a week - 2

Once or twice - 3

Once a week - 4

Not at all - 5

During the past 4 weeks, how often have you had to use your rescue inhaler?

3 or more times per day - 1

1 or 2 times per day - 2

2 or 3 times per week - 3

Once a week or less - 4

Not at all - 5

How would you rate your asthma control during the past 4 weeks?

Not controlled at all - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5

Total Score:

If your score is 19 or less, your asthma may not be under control. Make an appointment to discuss your results with your asthma nurse or doctor.

Do you have any of the following symptoms when you don’t have a cold: itchy, runny blocked nose, catarrh or sneezing?

Occasionally causing a little bother

Quite a bother

A lot, but causing little bother

A lot, causing a lot of bother

Flu Vaccination

Annual Flu Vaccination is recommended for all patients with severe asthma (this excludes patients under 6 months of age and those who need occasional reliever inhaler only). Flu vaccinations will be available from October.

If you DO NOT want a flu vaccination please tick this box

If there are any issues/concerns you have about your asthma please enter them below:

Informed Dissent

Please sign if you DO NOT wish to attend for your review.

It is strongly recommended that any person with a long term health condition should
receive regular care and follow up. If however, against our advice you decide that you do not wish to attend for an annual review this year, then we would be grateful if you would read and sign the form below and return it to your Surgery. A routine reminder for your annual review will be sent to you in a year’s time and you are welcome to make an appointment for a review at any time should you change your mind.

I assume and take full responsibility for the decision not to attend the surgery for a review of my condition(s) and confirm that I understand the risks of not attending for a regular review.

Name:

Signed:

Date:

Date of Birth:

St Thomas Medical Group

Asthmatic Patient Annual Screening Questions

St Thomas Health Centre, Exwick Health Centre

Flu Vaccination

Informed Dissent

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