Asthma Screening Form About You Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Email Address: Your Asthma Review In the last month have you had difficulty sleeping due to your asthma (including cough)? Yes No Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? Yes No Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? Yes No 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 No Please give details Since your last review, have you needed a course of steroid tablets to get your asthma under control? Yes No Do you smoke? Yes No Did you have a flu vaccination last flu season? Yes No Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?) Please note that the details you give will be used to update your medical records.