Yiewsley Family Practice

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Asthma Questionnaire

Asthma Questionnaire

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This Asthma questionnaire is for patients aged 8 and over. If you under 16, please ask your parent or guardian to complete it for you.

Patient Details
Patient Name
Patient Address
Address Post Code
Patient Date of birth (e.g. 23rd August 1976)

With regards to your asthma do you have problems with:
waking at night with coughing, wheezing, shortness of breath or a tight chest
being short of breath on waking up in the morning
needing more and more reliever treatment, or reliever not working very well
being unable to continue your usual level of activity or exercise

Are you a smoker?
If you are a smoker, how much do you smoke?

Peak Flow Readings Please provide the reading details and the date. For further information regarding Peak Flows please click here

Name/details of parent or guardian completing form (If applicable)

NB : If you answered 'YES' to any questions your asthma may not be controlled. Please contact the surgery to make an appointment with the asthma nurse or Doctor.