Asthma Review CDM Asthma Review Please complete this form so that we can review your Asthma. We would highly recommend reading the Asthma UK website. It is full of helpful information telling you about your asthma and how to better manage it. On submission of this form: We will contact you for a review if you asthma control is poor or you have indicated you would like to speak to a clinician. We will continue your current treatment if your control is good and you have indicated that you would not like to speak to a clinician. This review works well on mobile but it is easier on a computer. Tick here if you would like to email yourself this review to complete on computer. (Instant) Your Email * Your Details Patient Name * Date of Birth * Mobile number * Email (If you’d like a copy of your review) Inhaler Use How often do you use your RELIEVER? (blue inhaler) * Less than once a day Once a day Twice a day Three times daily Four or more times daily If you have one, how often do you use your PREVENTER? (regular daily inhaler) * Don’t have one One puff daily Two puffs daily One puff twice daily Two puffs twice daily Asthma Control During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home? * None of the time A little of the time Some of the time Most of the time All of the time During the last 4 weeks, how often have you had shortness of breath? * None of the time A little of the time Some of the time Most of the time All of the time During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning? * None of the time A little of the time Some of the time Most of the time All of the time During the last 4 weeks, how often have you used your reliever inhaler? * None of the time A little of the time Some of the time Most of the time All of the time How would you rate your asthma control during the last 4 weeks? * Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled Asthma Control Test Result Score < 20 Your asthma does not seem well controlled. It would probably help to have your treatment reviewed and increased. This will be discussed at your review. Score of 20-24 Your asthma seems reasonably well controlled. It would be reasonable for you to stay on your current treatment or possibly review and increase your treatment. This will be discussed at your review if you like. Score of 25 Your asthma appears to be VERY WELL CONTROLLED. We would recommend considering reducing your current treatment and reviewing it again in a few months. It would also be reasonable to simply continue your current treatment if you are happy. Inhaler Technique Inhaler technique is VERY important. Taking an inhaler is not like taking a pill. An inhaler will only work well if it’s taken well. Poor inhaler technique means the medicine doesn’t get to where it’s needed and can lead to your asthma giving you lots of symptoms. Which inhaler device types do you use? Clicking will reveal a video helping your technique. * logo required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms highrise mailchimp feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label authorize activecampaign aweber campaignmonitor constant_contact getresponse googlesheets building hubspot icontact mailpoet paypal icon sendinblue sendy salesforce salesforcealt stripe stripealt twilio woocommerce wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Zapier Preview MDI Ellipta Easibreathe Turbohaler Accuhaler Aerochamber Volumatic Would you like to go over your inhaler technique with a clinician? * YES, I WOULD LIKE TO GO OVER MY TECHNIQUE No thanks. I am happy with my technique Would you like a SPACER device? (see above) This can often often help if you are struggling to take your inhaler properly. * YES, PLEASE GIVE ME A SPACER No thanks. Environmental factors Many environmental or lifestyle factors can worsen or even cause asthma. To best control your asthma you must ensure that you: do not smoke maintain a healthy weight keep potential ASTHMA TRIGGERS to a minimum around your home and work such as dust and pollen. Smoking significantly worsens asthma. Do you smoke? Yes – Please consider the stop smoking information and clinic details below No Here is some helpful information on stopping smoking. It includes how to access specialist clinics that can support you and also prescribe medication to help you stop. Stop smoking – “QUIT YOUR WAY SCOTLAND” How is your asthma on days away from work? * Same Better Worse How is your asthma when you are on Holiday? * Same Better Worse OCCUPATIONAL ASTHMA. There is a possibility that your work is worsening or even causing your asthma. We will discuss this at your review. * Please confirm that you have considered speaking to your employer to discuss reducing asthma triggers at work. Peak Flows and your Asthma Plan Even people with well controlled asthma will occasionally have worsening symptoms or even an asthma attack. It is important that everyone with asthma has an asthma plan so that you know what to do if you have an attack. CLICK HERE to get the NHS Lothian asthma plan. “Peak Flow” readings taken with a “Peak Flow meter” can help you tell when your asthma control is poor and when to use your asthma plan. Would you like a peak flow meter? YES. Please prescribe me a PEAK FLOW METER No thanks I already have one Usual Best Peak Flow (if you have a peak flow meter) Step up your treatment as per your Asthma Plan if your peak flow is less than: Seek urgent medical attention if your peak flow is less than: Would you like to discuss an asthma plan with a clinician? * YES. I would like to DISCUSS AN ASTHMA PLAN No thanks, I already have a plan that I am happy with This is the end of your Asthma eReview. How would you like to proceed? * I am happy with my asthma control. Please CONTINUE my inhalers for the next year. I am happy with my asthma control and I would like to REDUCE the strength of my preventer inhaler I would like to discuss my Asthma by TELEPHONE I would like to discuss my Asthma FACE TO FACE in the practice Any final comments on your asthma? 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. Consent * I agree to the privacy policy © 2022 Kristian Turnbull CAPTCHA If you are human, leave this field blank. Submit
