Asthma Check
Please tell us your Name, Address and Date of Birth
Do you usually have any asthma symptoms that wake you up during the night or earlier than usual in the morning at least once a week?
How often do you get your usual asthma symptoms during the daytime
How often do your asthma symptoms affect any of your usual activities (eg at school, work, housework, sport)?
How often do you use your BLUE inhaler in a week?
Are you regularly coughing up phlegm?
When you have asthma symptoms and need to take your inhaler for immediate relief, do you feel it works?
Do you smoke?
If Yes to the above question, how mkany cigarettes do you smoke per day? (if you are currently a smoker who is considering giving up and would like any help, please don’t hesitate to contact the surgery or ring your local smokestop service on 0800 00 76653 or visit https://www.dorsetforyou.com/public-health-dorset/your-health/smoking.
If you are a non-smoker, please state: