Hobs Moat Medical Centre
Ulleries Road, Solihull, B92 8ED
Tel: 0121 742 5211     Fax: 0121 722 8000     Out of Hours: 111
When we are closed please call 111 for all health advice. A&E is for EMERGENCIES only - please use services carefully - call 111 when we are closed for the out of hours services!! Read 'Surgery news' today stay ahead of the game! Do you have a Health Question? see if we can answer it by checking out 'health topics!' Find embarrassing bodies helpful - join the online chats on surgery news! For more information check our our really useful page

Asthma Questionnaire

Thank you for taking the time to fill in this simple questionnaire about how your asthma is affecting you. You have been given this because it is some time since we last saw you for an asthma check. Your answers will help us to make sure that your asthma is as well controlled as possible. It may be that even if you think your asthma control is satisfactory, it may be troubling you more than you realise. We may be able to control your asthma even more effectively so that you can enjoy life to a greater degree.

Signs and Symptoms of Asthma:

Asthma symptoms can occur regularly or on contact with specific trigger factors. The commonest ones are:

  1. Coughing at night
  2. Wheezing (particularly with a cold or viral infection)
  3. Tightness of the chest
  4. Restricted activity – e.g. by wheezing, shortness of breath or cough

Signs of worsening Asthma:

  1. Needing to use your reliever (usually blue) more often than normally
  2. A falling peak flow or increased differences between the morning and evening readings.

If you experience any of these symptoms you should make an appointment for an asthma check.

NOTE: You can save your details and automatically populate this form by creating an account.
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Asthma Questionnaire

Asthma Questionnaire

Thank you for taking the time to fill in this simple questionnaire about how your asthma is affecting you. You have been given this because it is some time since we last saw you for an asthma check.

By completing the form, your team at the surgery will be able to calculate how well controlled your asthma is. They may be in touch to either discuss your asthma over the telephone or invite you in for a review

  • / /
    Pick a date.
  • If you do not have a home telephone number please enter your main contact telephone number here instead.

  • Please answer the following questions:
      All of the Time Most of the time Some of the time A little of the time None of the time
    During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home
    During the past 4 weeks, how often have you had shortness of breath?
    During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, sohrtness of breath)wake you up at night or earlier than usual in the morning?
    During the past 4 weeks, how often have you used your reliver inhaler (usually blue)?
  • Please answer the following question:
      Not controlled Poorly controlled Somewhat controlled Well controlled Completely controlled
    How would you rate your asthma control during the past 4 weeks?
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