Pewsey Surgery

Asthma Questionnaire (1)

Asthma Questionnaire

Please can your add your full name and date of birth into box below.

We would be grateful if you could advise us of your current asthma symptoms and level of control. Please select the score that applies to your current symptoms:

1. Over the last 12 months your asthma causes DAYTIME symptoms:

0(score) Never

1(score) 1-2 times a month

2(score) 1-2 times a week

3(score) Most days

2. Over the last 12 months your asthma causes NIGHTIME symptoms:

0(score) Never

1(score) 1-2 times a month

2(score) 1-2 times a week

3(score) Most days

3.Over the last 12 months your asthma LIMITS YOUR ACTIVITY:

0(score) Never

1(score) 1-2 times a month

2(score) 1-2 times a week

3(score) Most days

IF YOU HAVE SCORE 2 OR MORE ON ANY ONE OF THE INDIVIDUAL QUESTIONS THEN PLEASE BOOK IN FOR AN ASTHMA REVIEW AT THE SURGERY.

Smoking status: (please tick)

Never smoked tobacco

Ex-smoker

Cigarette smoker

Cigar smoker

Pipe smoker