Skip to content
0141 641 3827
Out of hours: 111
Silverbank Surgery
Home
About Us
Appointments, Tests & Referrals
Clinics & Services
Your Care
Your Record
Young People
Contact
Menu
Home
About Us
Appointments, Tests & Referrals
Clinics & Services
Your Care
Your Record
Young People
Contact
Search
Search
Close this search box.
Asthma Review Form
Silverbank Surgery
>
Your Record
>
Health Review Forms
>
Asthma Review Form
Asthma Review
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Asthma Review
When was your asthma diagnosed?
*
Less than 5 years ago
More than 5 years ago
More than 10 years ago
In the last month have you had difficulty sleeping due to your asthma (including cough)?
*
Yes
No
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?
*
Yes
No
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?
*
Yes
No
How often do you need to use your reliever inhaler?
*
Never
1-2 times a month
1-2 times a week
1-2 times a day
2+ times a day
Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?
*
Yes
No
Please provide details:
*
Have you been prescribed oral steroids to control your asthma since your last review?
*
Yes
No
Do you smoke?
*
Yes
Never smoked
Ex-smoker
Please list the inhalers you use:
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
If you are human, leave this field blank.
Send
Local support
Housing, health & much more
Local support
Self-help
Assess your own symptoms
Self-help guides
Services directory
Find a local health service
Services directory
