Asthma Control Form Asthma Control Form Full Name: * Date of Birth: * Please use date format DD/MM/YYYY Phone Number: Email Address: * How often does your asthma cause daytime symptoms? * Daytime symptoms 1 to 2 times per month Most days 1 to 2 times per week Never causes daytime symptoms How often does asthma limit activities? * Limiting activities Not limiting activities Increasing exercise wheeze Asthma restricts exercise Sometimes restricts exercise Severely restricts exercise Never restricts exercise Asthma limits walking up hills or stairs Asthma limits walking on the flat Asthma limits exercise to 1 to 2 times a week How often does asthma disturb sleep? * Disturbing sleep Not disturbing sleep Asthma causing night waking Causes symptoms most nights Disturbs sleep frequently Never disturbs sleep Asthma disturbs sleep weekly Causes night time symptoms 1 to 2 times per week Causes night time symptoms 1 to 2 times per month Never causes night time symptoms Asthma Control In the past 4 weeks, how often did your asthma keep you from getting as much done at work, school or home? * All of the time Most of the time Some of the time A little of the time None of the time During the past 4 weeks, how often have you had shortness of breath? * More than once a day Once a day 3 to 6 times a week Once or twice a week Not at all 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 2 or more nights a week Once a week Once or twice Not at all During the past 4 weeks, how often have you had to use your rescue inhaler? * 3 or more times a day 1 or 2 times a day 2 or 3 times a week Once a week or less Not at all How would you rate your asthma control during the past 4 weeks? * Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled Score: If your score is 19 or less, your asthma may not be under control. Please complete this form and also book for your annual review. Do you have any of the following symptoms when you don't have a cold: itchy, runny/blocked nose, catarrh or sneezing? No Occasionally causing 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). 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 here: Informed Dissent 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 tick the box below. 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. Date: Submit
