Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

Mickleover Medical Centre NHS GP Surgery in Derby

Asthma questionnaire

Asthma Review

Acknowledgement *

I understand that this questionnaire is for an asthma review and may not be seen by the practice for up to 7 days. I will seek urgent medical help if I have severe symptoms by calling the practice, NHS 111, or attending A&E.

How often does your asthma cause symptoms during the day? *

Never

1-2 times per month

1-2 times per week

Most days

How often does your asthma cause symptoms during the night? *

Never

1-2 times per month

1-2 times per week

Most days

How often does your asthma limit your activities? *

Never

1-2 times per month

1-2 times per week

Most days

How many asthma exacerbations (attacks) have you had in the past year? *

How many times have you attended Accident and Emergency department since your last asthma review? *

Please select the types of inhalers that you use: *

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

How many times per day do you use your inhaler? *

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *

All of the time – 1

Most of the time – 2

Some of the time – 3

A little of the time – 4

None of the time – 5

During the past 4 weeks, how often have you had shortness of breath? *

More than once a day – 1

Once a day – 2

3-6 times a week – 3

1-2 times a week – 4

Not at all – 5

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *

4 or more times a week – 1

2-3 nights a week – 2

Once a week – 3

Once or twice – 4

Not at all – 5

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *

3 or more times a day – 1

1-2 times a day – 2

2-3 times a week – 3

Once a week or less – 4

Not at all – 5

How would you rate your asthma control during the past 4 weeks? *