Asthma Review Forms Asthma Review Form For patients who are due an annual asthma review. Name First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone NumberAddress Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address Optional Asthma Review QuestionnaireWhen was your asthma diagnosed? OptionalLess than 5 years agoMore than 5 years agoMore than 10 years agoIn the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? OptionalNoYes, every dayYes, 1 – 2 times each weekYes, 1 – 2 times each monthYes, 1 – 2 times each yearYes, see below for detailsDetails of sleeping difficulties: OptionalIn the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? OptionalNoYes, every dayYes, 1 – 2 times each weekYes, 1 – 2 times each monthYes, 1 – 2 times each yearYes, see below for detailsDetails of symptoms during the day: OptionalIn the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? Yes Optional No Optional Have you ever had your peak flow measured at the surgery? Yes Optional No Optional If yes, do you know your best PEFR value Optionalml/min6. Are you happy with your inhaler technique? Yes Optional No Optional Have you ever smoked? Yes Optional No Optional If 'yes' Do you smoke now? Yes Optional No Optional If 'Yes' how many do you smoke each day? OptionalIf 'No' when did you quit? If 'No' when did you quit?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920There are plenty of options available to help you quit. Is this something you would like us to contact you about? Yes Optional No Optional Asthma Control ScoreDuring the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?All the time – 1Most of the time – 2Some of the time – 3A little of the time – 4None of the time – 5During the past 4 weeks, how often have you had shortness of breath?More than once per day – 1Once per day – 23 – 6 times per week – 31 – 2 times per week – 4None at all – 5During 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 – 12 – 3 nights a week – 2Once a week – 3Once or twice – 4Not at all – 5During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?3 or more times a day – 11 – 2 times a day – 22 – 3 times a week – 3Once a week or less – 4Not at all – 5How would you rate your asthma control during the past 4 weeks?Not Controlled – 1Poorly Controlled – 2Somewhat Controlled – 3Well Controlled – 4Completely Controlled – 5