Asthma Review Form

This form is to be used as a pre-check for your routine asthma review, to decide if you need further assessment.

If you feel that you need urgent medical attention for your asthma or need medication urgently, please submit the form and contact the surgery in the normal way. If you need urgent medical attention when the surgery is closed, please ring 111.

Asthma Questionnaire
Patient Name
Patient Name
An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation.
We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044