Provide Asthma Screening

Asthmatic Patient Annual Screening Questions

This form is for patients who already have a diagnosis of asthma. If you have not been diagnosed with asthma, but suspect you may have it, please make an appointment to see your doctor rather than using this form.

We aim for the asthma nurse to review your answers within three working days, but at busy times it may take longer.

Once a year please select the surgery you are from below and fill in the form. If you answer “yes” to any of the questions you are encouraged to book an Asthma Review.

St Thomas Health Centre, Exwick Health Centre

* = Information must be provided

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.

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.

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.