THE ROYSTON HEALTH CENTRE PRACTICE
Dr Christopher Day
MB, BS, MRCGP
Dr John Hedges
TD, BSc, MB, BS, FRCP, FRCGP, MAcadMEd
Dr Theresa Leighton
MB, BS, BSc, DRCOG, DFFP
Dr Fabienne Smith
MD, MRCPCH, MSc
Dr Kenneth van Terheyden
MB, BS
Dr John Wright
MA, MB, BS,MRCGP, DFFP
Name:
DOB:
Address:
Dear
Our records show that you have a diagnosis of asthma and had asthma medication prescribed in the last
year.
SIGN/BTS/NICE guidelines advise that you have an annual asthma review. Therefore please make an
appointment with one of our respiratory accredited nurses.
The aim of asthma treatment is to maintain you on the lowest dose of medications to enable you to be
symptoms free, which may mean increasing or decreasing medication appropriately.
It is also important that every asthma patient has a personalised written asthma plan and knows what to
do in an asthma emergency. Therefore if you have not got one of these we strongly advise that you book
an appointment even if your asthma is currently well controlled.
However if you feel a review would be an inappropriate use of your time please could you answer the
following questions and return this form to us. Alternatively you can submit this form to our website
www.roystonhealthcentre.co.uk by clicking on the Health Questionnaires link and select Asthma
Review Form.
Do you have an in date not fully used 'BLUE' reliever inhaler (Salbutamol or Terbutaline)? YES/NO
If you have emptied 2 of these inhaler devices due to frequent usage over the last 2 months this indicates
that your asthma is not well controlled and you need to make an appointment for review.
Do you smoke? YES/NO Would you like help in stopping smoking? YES*/No
*If yes please book an appointment with our Cessation Advisor at the Health Centre
Did you smoke in the past? YES/NO
Do you have difficulty using your inhaler? YES/NO
In the last MONTH have you had any difficulty sleeping due to asthma symptoms including cough?
NEVER/SOMETIMES/OFTEN
Does exercise cause wheeze or shortness of breath? NEVER/SOMETIMES/OFTEN
Does asthma interfere with
NEVER/SOMETIMES/OFTEN
your
usual
daily
activities
(housework,
Melbourn Street, Royston, Herts, SG8 7BS
Telephone 01763 242981 - Fax 01763 249197
Email: enquiries.roystonhc@nhs.net
VAT NO: 876657267
school.
work)?
Do sore throats and colds trigger your asthma? NEVER/SOMETIMES/OFTEN
Have you had asthma symptoms throughout the day? For example Wheeze cough chest tightness or
breathlessness? NEVER/SOMETIMES/OFTEN
We recommend you have the influenza vaccination annually and you can arrange this from September to
December by phoning reception to book an appointment for a flu clinic which are also run on some
Saturdays and evenings.
Do you intend to have a flu vaccination this year? YES/NO
If you are 65 years and over we also recommend that you have the one off pneumonia vaccination which
you can have at the same time as the flu vaccination or can book an appointment via reception any time
of the year for this.
Have you had or do you intend to book for the pneumonia vaccination? YES/NO
What inhalers are you using regularly at the moment?
Do you have a personalised written asthma plan and know what to do in an asthma emergency? YES/NO
(If no we advise you do need to book an appointment).
Please give your latest peak flow reading:
If you are over 7 years of age have you ever had a Spirometry breathing test to confirm diagnosis of
asthma? YES/NO
Do you intend to book an appointment with the asthma nurse? YES/NO
Thank you for taking the time to fill in and return this form.
You may find information of interest on http://www.asthma.org.uk.
The Health Centre Practice.
Melbourn Street, Royston, Herts, SG8 7BS
Telephone 01763 242981 - Fax 01763 249197
Email: enquiries.roystonhc@nhs.net
VAT NO: 876657267