Tel: 0141 465 1919
Out of hours: 111
Marythill Health & Care Centre, Glasgow G20 8FB

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Asthma Review Form

Gairbraid Medical Practice > Managing Your Health > Health Review Forms > Asthma Review Form

Asthma Review

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your Asthma Review

When was your asthma diagnosed? *

In the last month have you had difficulty sleeping due to your asthma (including cough)? *

Yes

Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *

Yes

Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *

Yes

How often do you need to use your reliever inhaler? *

Never

1-2 times a month

1-2 times a week

1-2 times a day

2+ times a day

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma? *

Yes

Please provide details: *

Have you been prescribed oral steroids to control your asthma since your last review? *

Yes

Do you smoke? *

Yes

Never smoked

Ex-smoker

Please list the inhalers you use:

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Gairbraid Medical Practice

Maryhill Health & Care Centre
51 Gairbraid Avenue
Maryhill
Glasgow G20 8FB

Contact Us

Telephone: 0141 465 1919
Out of hours: 111

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