Asthma Review Asthma Questionnaire Patient Name * Patient Name First First Last Last Date of Birth * Address * Address Address Address City City County County Postcode Postcode How often does your asthma case symptoms during the day? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) How often does your asthma cause symptoms at night? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most nights) How often does your asthma limit your everyday activities? e.g. school / work / housework * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Number of asthma exacerbations (attacks) have you had in the past year? * An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation. How many times have you attended Accident and Emergency Department since your last asthma review? * What triggers your asthma? * Animals Airborne dust Cold air Damp Dust mites Emotion Exercise Humidity Perfume Pollen Respiratory infection Seasonal Tobacco smoke Warm air Wind No triggers identified If you are human, leave this field blank. Next
