Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

How to use your inhaler – Asthma UK

Asthma Review - Eastfield

About You

Please use this date format: DD/MM/YYYY.
Responses we send will go to this email address

Smoking Status

Your Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)?
Does it disturb your sleep:
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?
Asthma causes daytime symptoms:
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?
Asthma limits activities:
If you have answered 'yes' to any of the above questions and feel you need to have your asthma reviewed, please telephone the surgery reception to make an appointment with one of our asthma nurses.

Please note that the details you give will be used to update your medical records.

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