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Menu
Home
About Us
Contact
Send a Message
Contact Telephone Numbers
Location
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Teenage Friendly
Website
Student Doctors
Clinics & Services
Appointments, Tests & Referrals
Private Healthcare Responsibilities
Referral to Hospital by your GP
Who Should I see?
Tests & Investigations
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Flu Vaccination Clinics
Travel Clinic & Holiday Vaccinations
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Tramways Medical Centre
>
Your Record
>
Health Review Forms
>
Asthma Review Form
Asthma Review Form
Asthma Review
First Name
*
Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Asthma Review
When was your asthma diagnosed?
*
Less than 5 years ago
More than 5 years ago
More than 10 years ago
In the last month have you had difficulty sleeping due to your asthma (including cough)?
*
Yes
No
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?
*
Yes
No
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?
*
Yes
No
How often do you need to use your reliever inhaler?
*
Never
1-2 times a month
1-2 times a week
1-2 times a day
2+ times a day
Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?
*
Yes
No
Please provide details:
*
Have you been prescribed oral steroids to control your asthma since your last review?
*
Yes
No
Do you smoke?
*
Yes
Never smoked
Ex-smoker
Please list the inhalers you use:
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Teenage Friendly
Website
Student Doctors
Clinics & Services
Appointments, Tests & Referrals
Private Healthcare Responsibilities
Referral to Hospital by your GP
Who Should I see?
Tests & Investigations
Clinics
Flu Vaccination Clinics
Travel Clinic & Holiday Vaccinations
Online Services
Register for Online Services
GP Online Services
Practice Services
Your Record
Keep us up to Date
Health Review Forms
Help & Support
Help & Support Organisations
Who can help me?
News