Heath Lane
Medical Centre
Asthma Questionnaire for Annual Asthma Review
Name
DOB:
Do you have a peak flow meter at home?
What is your most recent reading?
How tall are you?
What is your current weight?
Do you smoke?
If no have you ever smoked?
If yes how many do smoke each day?
Does your asthma cause you to cough, be short of breath, tight-chested or wheeze during the day?
During the day, does your asthma limit you undertaking any activity?
Does your asthma wake you at night?
How often have you needed to take your reliever inhaler (usually blue)?
How often per week do you use your reliever inhaler?
What dose of preventer inhaler (usually brown)
do you take?
FLU AND PNEUMONIA
VACCINATION:
Flu vaccine
is indicated annually for all people who have asthma, both adults and children.
Pneumonia vaccine is indicated as a once in a life time vaccination.
Remember
you are entitled and encouraged to have an annual influenza vaccination. Please telephone the surgery as soon as
possible, for an appointment from August.
If after
reviewing your answers we feel that a review of your medication is indicated,
we will write to you and offer an appointment or a telephone consultation
Thank you