Questions Related to Asthma

In order to prescribe treatments for Asthma our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

How long have you had asthma?

Do you use a prevention medication?

Yes No

Do you use a reliever inhaler?

Yes No

How often do you normally use your inhaler?

What is your average peak flow?

In the last 5 years, have you been admitted to hospital because of asthma or another respiratory problem?

Yes No

Do you have any cardiac problems?

Yes No

Are you pregnant or breast feeding?

Yes No

Do you suffer from any conditions other than asthma?

Yes No

Do you have low levels of calcium in your blood?

Yes No

Do you smoke?

Yes No

I understand it is recommended I review my inhaler use with my GP or hospital consultant once a year.

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