Asthma Review - Clackmannan and Kincardine Medical Practice

Please confirm you have watched the inhaler technique video *

Yes

What is your Asthma Control Test (ACT) Score? *

Height *

Weight *

Do you smoke? *

Yes No

If you do smoke, how many do you smoke per day?

Do you have difficulty sleeping due to your asthma (including cough)? *

Does your Asthma wake you during the night? *

Yes No

Do you use your blue inhaler 3 or more times per week? *

Yes No

What is your peak flow reading? *

Do you have an asthma management plan? *

Yes No

How do you rate this online form? *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

CDM - Asthma Review Form

Further Information