Contact Details
Full Name
Date of Birth
Address and Postcode
NHS Number (optional)
Preferred Contact Details (email or phone)
Questionnaire
Please select... Less than 5 years ago 5-10 years ago Over 10 years ago When was your asthma diagnosed?
Further Details
Further Details
If you still smoke, how many do you smoke each day?
If you have quit smoking, when did you quit?
Asthma Control Score
During the last 4 weeks, how often has your asthma prevented you from getting the required jobs done at work, school or home?
Please select... 1 - All of the time 2 - Most of the time 3 - Some of the time 4 - A little of the time 5 - None of the time
During the last 4 weeks, how often have you had shortness of breath
Please select... 1 - More than once a day 2 - Once a day 3 - 3-6 times a week 4 - 1-2 times a week 5 - None at all
During the last 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?
Please select... 1 - 4 or more nights a week 2 - 2-3 nights a week 3 - Once a week 4 - Once or twice a month 5 - Not at all
During the last 4 wees, how often have you used to reliever inhaler (usually blue)?
Please select... 1 - 3 or more times a day 2 - 1-2 times a day 3 - 2-3 times a week 4 - Once a week or less 5 - Not at all
How would you rate your asthma control during the past four weeks?
Please select... 1 - Not Controlled 2 - Poorly Controlled 3 - Somewhat Controlled 4 - Well Controlled 5 - Completely Controlled
Measurements
What is your BMI? (More Information on how to calculate can be found in the home page)
If you have a machine, what is your Blood Pressure? (More Information on how to measure can be found in the home page)
If you have a machine, what is your Pulse Rate? (More Information on how to measure can be found in the home page)
If you have a machine, what is your Peak Flow Score? (More Information on how to measure can be found in the home page)
