Adult Asthma
Questionnaire

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Asthma Adult Questionnaire

Required fields are marked with an asterisk (*).

This Questionnaire is to review your Asthma, and your practice may not see this report for up to 7 days. If you have severe symptoms, please contact the practice directly for urgent appointment or call 111

 

An exacerbation is where your symptoms got worse, your reliever did not help and you needed to seek medical attention.

Enter an approximate number is fine here.

Please not that your answers will not be seen immediately and you should direct any urgent queries to your healthcare team

Please not that ‘smoking status’ refers to smoking tobacco products, and NOT the use of e-cigarettes or ‘vaping’. If you only use e-cigarettes or ‘vape’ then please select ‘Ex-smoker’ (if you used to smoke tobacco products or ‘Never smoked’.

Please not that your answers will not be seen immediately and you should direct any urgent queries to your healthcare team

Privacy Consent – This form collects personal and medical information about you/ We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage submitted data.

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