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

    Have you been told you are on a “MART” or “AIR” regime for your asthma?
    If you are not on a MART regime how many puffs morning and night do you take of your steroid inhaler?
    If you have a blue inhaler, how often do you use it?
    If you use your morning and night inhalers "as required" (MART regime)  how many extra puffs a week do you take?
    If you are on an AIR regime how many puffs of you inhaler do you take
    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?
    In the last 12 months, have you needed to take a course of steroid tablets (like prednisolone) or antibiotics because of your asthma?
    Do you smoke?
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Page last reviewed: 02 July 2025
Page created: 20 November 2023