This survey is now closed
Q1. In the last month / week have you had difficulty sleeping due to your asthma (including cough symptoms)?


Q2. Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day?


Q3. Has your asthma interfered with your usual daily activities? (e.g. school, work, house work)


Q4. I have checked my inhaler technique at :
but I want a nurse to review this with me also.


Q5. My current smoker status is:


You can find further stop smoking help at:

Q5. In answering yes to any one of questions 1-4 above I confirm that there has been a change in my asthma control or technique and I need an asthma review or I would like help to stop smoking. I want the practice to contact me on the details below to arrange an asthma nurse review.


Q6. Patient Name

Q7. Patient Address

Q8. Patient contact tel number or e-mail

Q9. If you have any other questions, comments or feedback please let us know here:

This survey is now closed