Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Your Asthma

Have you had your usual Asthma Symptoms during the day (cough,wheeze,chest tightness or breathlessness?
Has your Asthma interfered with your usual activities eg housework, work/school?

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?
During the past 4 weeks, how often have you had shortness of breath?
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
How would you rate your asthma control during the past 4 weeks?