Asthma Review Form

Asthma Review Form

This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the Advanced Nurse Practitioner or GP.

  • Your Details

    Date of birth
    For example, 15 3 1984

  • Asthma Review Form

    Do you have a blue inhaler (eg Salbutamol/Ventolin)
    If yes, how often do you use it:
    Have you been told you are on a “MART” regime for your asthma?
    Have you been given a printed/written asthma management plan?
    Do you feel confident with your inhaler technique?
    In the last month has your sleep been disturbed by your asthma (e.g. waking up coughing during the night)?
    Do you have asthma symptoms every day (cough/wheeze)?
    Does your asthma interfere with your day to day activities?
    Have you had any time over the last year you have taken steroids and/or antibiotics for your asthma?
    Do you smoke?
    Do you have any concerns about your asthma at the moment?

  • Communication Preferences

    We collect your personal and medical details to process your request, verify your registration, and update your medical record held by Eastfield Medical Practice and NHS Scotland. We handle your information in strict confidence. Please read our Privacy Policy to learn more about how we protect your data.

    I consent to the practice collecting and storing my data from this form.
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Page last reviewed: 26 January 2026
Page created: 20 November 2023