Asthma Questionnaire | Cherryvalley Group Practice

top of page

Kings Square, Kings Road, Belfast BT5 7BP

Tel: 028 9040 1844

HOME
ABOUT US
SERVICES
YOUR HEALTH
NEWS
CONTACT
ELECTRONIC CARE RECORD
PRACTICE POLICIES
More

Use tab to navigate through the menu items.

Asthma

Asthma Questionnaire

Please fill out the following form to help us assess how well controlled your asthma is.

First Name

Last Name

Date of Birth

Please tell us your smoking status *

Never smoked

Ex smoker

Current smoker

In the last month have you had any difficulty sleeping because of your asthma symptoms (including cough)? *

Yes, most nights

Yes, once-twice per week

Yes, once-twice per month

No, not at all

In the last month have you had your usual asthma symptoms during the day (cough/ wheeze/ chest tightness/ breathlessness)? *

Yes, most days

Yes, once-twice per week

Yes, once-twice per month

No, not at all

In the last month has your asthma interfered with your usual activities (household/ school/ work)? *

Yes, most days

Yes, once-twice per week

Yes, once-twice per month

No, not at all

Have you noticed you have a blocked or runny nose even when you don't have a cold? *

Yes

Yes, but I can identify certain triggers e.g. hayfever

Do you any of these things trigger your asthma? * Required

Colds and flu

Cigarette smoke

Exercise

Stress

Dust

Pollen / hayfever

Pets

None of the above

Are you happy with your inhaler technique? *

Yes

Have you got a peak flow meter? *

Yes

Can you tell us a recent peak flow reading?

Today's date

Thanks for submitting!

Kings Square, Kings Road, Belfast BT5 7BP, Northern Ireland

Tel: 0280 9040 1844

bottom of page