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ASTHMA HEALTH REVIEW

Personal Details

Full Name: Date of Birth: Postcode:

Asthma Health Review

Are you currently using medication for asthma?

Yes

If not, when was the last time that you used your medication?

How many times a day do you use your reliever (salbutamol)?

If you have a peak flow meter, what is your expiratory rate? Please note: the best, i.e. the highest, of three attempts.

Do you use a spacer device with your inhaler?

Yes

Have you been admitted to hospital because of your asthma in the past year?

Yes

Daytime Symptoms

Limiting Activities

Disturbing Sleep

General Comments:

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