Asthma Review Asthma Questionnaire Patient Name * Patient Name First First Last Last Date of Birth * Address * Address Address Address City City County County Postcode Postcode Are you experiencing your usual asthma symptoms during the day? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Is your asthma disturbing your sleep? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Does your asthma limit your everyday activities? E.g. school / work / housework? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Are you using your blue/reliever inhaler more than once a day? E.g. salbutamol, terbutaline? * YesNo Number of asthma exacerbations in the past year? * An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation. Are you a Smoker? * Never Smoked TobaccoLight SmokerModerate SmokerHeavy SmokerVery Heavy SmokerEx-Smoker We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044 If you are human, leave this field blank. Next