Charlton Medical Asthma Annual Review (for patients aged 8 & Over)
Name of Patient:
Date of review:
DOB:
IMPORTANT – DO NOT IGNORE.
PLEASE RETURN YOUR COMPLETED FORM TO THE SURGERY BEFORE
. IF YOU DO
NOT RETURN YOUR QUESTIONNAIRE YOU WILL BE UNABLE TO ORDER YOUR INHALERS ON
YOUR REPEAT PRESCRIPTION CARD WITHOUT HAVING TO COME TO THE SIT AND WAIT
SURGERY, TO BE REVIEWED.
For office use

.663
1
Over the last 4 weeks, has your asthma interfered with your
All the time
1
P
usual activities?
Most of the time
2
P
Some of the time
3
P
A little of the time
4
Q
None of the time
5
Q
2
On average over the last 4 weeks, how often have you had
shortness of breath during the daytime?
More then once a day
Once a day
3-6 times a week
1 -2 times a week
Not at all
1
2
3
4
5
q
q
q
u
s
3
On average over the last 4 weeks, how often did your
asthma symptoms wake you up at night or earlier than usual
in the morning? Asthma symptoms include
wheezing/coughing/shortness of breath/chest tightness.
4-7 nights a week
2-3 nights a week
1-2 nights a week
1-2 nights a month
Not at all
1
2
3
4
5
N
N
N
O
O
4
On average over the last 4 weeks how often have you used
your blue rescue inhaler? (Do NOT count use before
exercise to prevent exercise induced asthma)
3 or more times a day
1-2 times a day
3 times a week
2 times a week
Once a week or less
Not at all
1
2
3
4
5
5
5
How would you rate your asthma control?
Not controlled at all
Poorly controlled
Somewhat controlled
Well controlled
Complete control
1
2
3
4
5
6
Over the last 12 months how many times have you needed
treatment with steroid tablets (Prednisolone)?
4 or More
3
2
1
0
Don’t know
PATIENT PTO
Asthma Nurse/Doctor use only
A.
B.
If Q6 ? look at medication screen and Docman letters and answer.
Asthma Control Test
5 - 15
16 – 19
20 - 25
?
PAGE 2
Please Circle
7
8
9
10
Do you have a runny or blocked nose most of the time ?
Do you wish to have a flu vaccination this winter?
(Every year between October and December. Not needed if you just use a blue rescue inhaler)
Do you smoke?
If yes, how many per day?
If you are a smoker do you want to stop?
If you want to stop the surgery has a Help 2 Quit Nurse – Book at reception.
Yes
Yes
No
No
Yes
No
Yes
No
If you have NOT had to use ANY inhaler for over 12 months please tick this box
If your asthma questionnaire shows that your treatment needs increasing which is your preferred option:
Nurse/doctor increases treatment and reception contact me to collect new prescription
Telephone appointment with Asthma Nurse
Appointment with Asthma Nurse in Asthma Clinic
Thank you for taking the time and trouble to complete this questionnaire.
Asthma Nurse/Doctor use only
Coding
C
Circle worst colour 1st letter
D
Circle number – Is patient taking preventer
E
b
g
w
1
2
NO
Yes
.66YT Asthma annual review
Freetext #b or g or w & 1 or 2
ACTION
F
Worst Colour
Black
Grey
White
G
Q7
Action
Consider increasing Rx 2 steps or start at step 2 if on no Rx
Increase Rx 1 step
No change in Rx needed
If Yes, start Beconase/Nasonex if not on Rx for rhinitis.