Asthma Review

 
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Personal Details

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

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Asthma Control Score
(1) During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?: *
(2) During the past 4 weeks, how often have you had shortness of breath?: *
(3) During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?: *
(4) During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? : *
(5) How would you rate your asthma control during the past 4 weeks?: *
Your Score

Off Target

You have a score of 

Your asthma may not have been controlled during the past 4 weeks.

Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.

  • If you have symptoms, please book an appointment with a nurse or doctor as soon as possible or call 111
  • Alternative visit a pharmacist for further advice
  • Call 999 in life threatening situation.

On Target

Your score is 

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

If you are experiencing any problems with your asthma

  • Book an appointment with a nurse or GP as soon as possible

Well Done

Your score is 

Your asthma appears to have been under control over the past 4 weeks.

If you are experiencing any problems with your asthma

  • Book an appointment with a nurse or GP as soon as possible
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Additional Questions

Additional Questions

Please complete the additional questions below and then press submit to send your review to your Doctor.

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?: *
Since your last review, have you needed a course of steroid tablets to get your asthma under control?: *
Do you smoke?: *
Did you have a flu vaccination last flu season?: *
Please select the types of inhalers that you use: *
Do you have a personal asthma plan?: *

How to get an asthma action plan

If you’re not using an asthma action plan yet, it’s easy to get started:

  1. Download an asthma action plan here. If you can, print out a copy to take to your GP or asthma nurse.
  2. Book an asthma appointment with your GP or asthma nurse.
  3. At the appointment, talk through the plan with your GP or asthma nurse and fill it in together. You can do this by telephone or video call too if your appointment isn’t in the surgery. Ask them to save a copy. onto your notes and send it to you on email, SMS or WhatsApp.
Do you have a peak flow meter?: *
Would you like us to prescribe a peak flow meter to go to your nominated chemist?: *

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Bron-Y-Garn Surgery
Neath Road
Maesteg
CF34 9PW

Telephone: 01656 754200

All calls to and from the practice are recorded.

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