Contact Numbers
1. When was your asthma diagnosed? Please select... Less than 5 years ago More than 5 years ago Less than 10 years ago More than 10 years ago
2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? Please select... No Yes, 1-2 times each week Yes, 1-2 times each month Yes, 1-2 times each year Yes, see below for details
Please give details of your sleeping difficulties:
3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? Please select... No Yes, 1-2 times each week Yes, 1-2 times each month Yes, 1-2 times each year Yes, see below for details
Please give details of symptoms during the day:
4. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? Please select an option below... No Yes
5. Have you ever had your peak flow measured at the surgery? Please select an option below... No Yes
If 'Yes', do you know your best PEFR value?
7. Have you ever smoked? Please select... No Yes
Do you smoke now? Please select... No Yes
How many do you smoke each day?
If 'No', when did you quit?
8. During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? * Please select... All of the time = 1 Most of the time = 2 Some of the time = 3 A little of the time = 4 None of the time = 5
9. During the past 4 weeks, how often have you had shortness of breath? * Please select... More than once a day = 1 Once a day = 2 3 - 6 times a week = 3 1 - 2 times a week = 4 None at all = 5
10. During the past 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... 4 or more times a week = 1 2 - 3 nights a week = 2 Once a week = 3 Once or twice = 4 None at all = 5
11. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? * Please select... 3 or more times a day = 1 1 - 2 times a day = 2 2 - 3 times a week = 3 Once a week or less = 4 None at all = 5
12. How would you rate your asthma control during the past 4 weeks? * Please select... Not controlled = 1 Poorly controlled = 2 Somewhat controlled = 3 Well controlled = 4 Completely controlled = 5
