Asthma Review

Asthma Review

Name
MM slash DD slash YYYY
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, how often did you asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning ?
During the past 4 weeks, often do you need to use your reliever inhaler? *
How would you rate your asthma control during the past 4 weeks? *
Do you have an asthma management plan? *
Are you confident on what you need to do in an emergency
In the last 12 months, have you needed antibiotics or steroids for exacerbation of your asthma? *