Asthma

Asthma Questionnaire

Please fill out the following form to help us assess how well controlled your asthma is.

Please tell us your smoking status
In the last month have you had any difficulty sleeping because of your asthma symptoms (including cough)?
In the last month have you had your usual asthma symptoms during the day (cough/ wheeze/ chest tightness/ breathlessness)?
In the last month has your asthma interfered with your usual activities (household/ school/ work)?
Have you noticed you have a blocked or runny nose even when you don't have a cold?
Do you any of these things trigger your asthma?
Are you happy with your inhaler technique?
Have you got a peak flow meter?

Kings Square, Kings Road, Belfast BT5 7BP, Northern Ireland

Tel: 0280 9040 1844

© 2020 by Cherryvalley Group Practice.