Castle Place Asthma Review Questionnaire
We encourage all our patients with Asthma to attend the practice for an annual review, but we understand that some patients may not want to attend. This questionnaire gives a quick way for you to assess your asthma control. If you then wish to attend the practice for a review please ring the appointment line to make an appointment. If you DO NOT wish to attend for your review please complete the informed dissent section at the end of the questionnaire. Even if you decide you do not wish to attend for a review at this time you are always welcome to make an appointment at a later date.
Please Enter your Name:
Please enter your date of birth
The Asthma Control Test
The Asthma control test is a way to quickly assess your asthma control, giving you a simple score out of 25. Please read each question carefully and select you answer. Add up each of the 5 scores and enter it in the box below the questions. Then use the score guide below to learn how well you are controlling your asthma.
Q1. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?
Q2. During the past 4 weeks, how often have you had shortness of breath?
Q3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you at night or earlier than usual?
Q4. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
Q5. How would you rate your Asthma control during the past 4 weeks?
What was your total score out of 25
What does you score mean?
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19 or less: We ought to see you as your asthma may not be very well controlled and we may be able to help. We strongly recommend you make an appointment with one of our respiratory nurses for a review.
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20 or more: Your asthma appears to be reasonably well controlled. Ideally we would like to see you for a review but if you would prefer not to attend the surgery please complete the rest of the questionnaire and return it to the surgery.
Peak Flows
Do you measure your peak flow? If you do please record a typical reading
It is a good idea to have a peak flow meter and to check your measurements occasionally. If the measurement varies a lot it’s a sign your asthma is not well controlled and you might be at risk from an attack. In particular if your early morning readings are consistently lower than your evening readings your asthma may be inadequately controlled.
Inhaler Technique
Do you have any problems taking you inhaler?
Things people often forget with MDI inhalers (snorkel shaped one press):- Shake the inhaler before each puff; press inhaler as you breath, NOT before or afterwards; hold your breath for 10 seconds.
Smoking Status
What is your smoking Status
If you are a smoker no doubt you are aware smoking is bad for your health, especially if you are asthmatic. Apart from making your asthma potentially more difficult to control, it increases your chances of developing irreversible lung disease in the future.
Would you like help giving up smoking?
Flu Vaccinations
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 inhalers only). Please speak to one of the respiratory nurses if you do not know if you are eligible.
If you DO NOT want a flu vaccination please select NO.
Wellbeing Screening
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
Any Other Information
If there are any issues/concerns you have about your asthma please enter them below.
Thank you for completing the questionnaire to submit please click on send at the bottom of the page.
If you DO NOT wish to attend for a review of your asthma please let us know by completing the informed dissent section below.
Informed Dissent
PLEASE COMPLETE THIS SECTION ONLY IF YOU DO NOT WISH TO ATTEND FOR YOUR REVIEW.
It is strongly recommend 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 want to make an appointment for your annual review, then we would be grateful if you would read and sign the form below and return it to the practice. A routine reminder for your 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.