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 Are you experiencing your usual asthma symptoms during the day? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Is your asthma disturbing your sleep? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Does your asthma limit your everyday activities? E.g. school / work / housework? * No / NeverOnce or twice a monthOnce or twice a weekFrequently (Most days) Are you using your blue/reliever inhaler more than once a day? E.g. salbutamol, terbutaline? * YesNo Number of asthma exacerbations 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. Are you a Smoker? * Never Smoked TobaccoLight SmokerModerate SmokerHeavy SmokerVery Heavy SmokerEx-Smoker We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044 Next