Adult Annual Asthma Review Adult Annual Asthma Review Please complete the online form below to submit your annual review First Names Surname Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Please answer the questions below:1. During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home? All of the time (1) Most of the time (2) Some of the time (3) A little of the time (4) None of the time (5) 2. During the last 4 weeks, how often have you had shortness of breath? More than once a day (1) Once a day (2) 3 to 6 times a week (3) Once or twice a week (4) Not at all (5) 3. During the last 4 weeks, how often have your asthma symptons (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning? 4 or more nights a week (1) 2 to 3 nights a week (2) Once a week (3) Once or twice a month (4) Not at all (5) 4. During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)? 3 or more times per day (1) Once or twice per day (2) 2 or 3 times a week (3) Once a week or less (4) Not at all (5) 5. How would you rate your asthma control during the last 4 weeks? Not controlled at all (1) Poorly controlled (2) Somewhat controlled (3) Well controlled (4) Completely controlled (5) 6. Do you have an Asthma Management Plan? Yes and I am happy with it Yes but I think it needs changing No Not sure 7. Do you have a preventer inhaler? Yes, I use a Metered Dose Inhaler (e.g. Clenil, QVar, Seretide, Evohaler, Fostair, Flutiform) Yes, I use an Accuhaler Yes, I use an Autohaler Yes, I use a Breezhaler Yes, I use an Easi-breathe Yes, I use an Easyhaler Yes, I use an Ellipta Yes, I use a Forspiro/Airflusal Yes, I use a Genuair Yes, I use a HandiHaler (Spiriva) Yes, I use a NEXThaler Yes, I use a Respimat Yes, I use a Spiromax Yes, I use a Turbohaler (e.g. symbicort, pulmicort, bricanyl) Other Not Applicable – I don’t use a preventer inhaler 8. How many puffs of your preventer inhaler do you take in the MORNING? 0 puffs in the morning 1 puff in the morning 2 puffs in the morning 3 or more puffs in the morning Not applicable – I don’t use a preventer inhaler If your inhaler contains a steroid, brush your teeth or rinse your mouth with water and spit it out after every use to prevent mouth infections.9. How many puffs of your preventer inhaler do you take at NIGHT? 0 puffs at night 1 puff at night 2 puffs at night 3 or more puffs at night Not applicable – I don’t use a preventer inhaler 10. How do you manage if your Asthma is much worse than normal? Increase preventer use Separate reliever inhaler Monitor peak flow readings Start treatment course e.g oral steroids None of the above Symptoms of your asthma worsening may include persistent symptoms such as wheeze, tight chest, breathless, coughing, waking at night, breathing interfering with daily activities, using reliever inhaler three times per week, peak flow drops to around 50-75% of your best11. Have you had any exacerbations of your asthma in the last year? No, 0 exacerbations Yes, 1 exacerbation Yes, 2 exacerbations Yes, 3+ exacerbations An asthma exacerbation is a sudden progressive worsening of your symptoms such as shortness of breath, wheezing, cough and chest tightness. Exacerbations often require additional treatment, such as steroid tablets or hospital treatment.12. In the last year, have you been prescribed any oral steroids such as prednisolone tablets as a result of an exacerbation of your asthma? No, 0 courses of oral steroids Yes, 1 course of oral steroids Yes, 2 courses of oral steroids Yes 3 or more course or oral steroids 13. Do you smoke? Never smoked Ex smoker Trivial smoker (less than one cigarette per day) Light smoker (1-9 cigarettes per day) Moderate smoker (10-19 cigarettes per day) Heavy smoker (20-39 cigarettes per day) Very heavy smoker (40+ cigs/day) 14. What triggers your Asthma?Taking you asthma medicine each day will help reduce your reaction to these triggers. Avoiding them where possible will also be helpful. People with allergies need to be extra careful as attacks can be more severe.Is there anything else you'd like to let us know about your Asthma?
