Asthma review (adults)

Full Name:

Phone Number:

Please provide an up to date blood pressure reading:

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Height (in Metres):

Weight (in KG):

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

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