Asthma Review Asthma Review Name First Last Date of Birth MM slash DD slash YYYY PhoneEmail During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? * All of the time most of the time some of the time a little of the time none of the time During the past 4 weeks, how often have you had shortness of breath? * more than once a day once a day 3-6 times a week 2-4 times a week not at all 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 ? 4 or more times a week 2-3 times a week once a week not at all During the past 4 weeks, often do you need to use your reliever inhaler? * 3 or more times a day 1-2 times a day 2-3 times a week once a week not at all How would you rate your asthma control during the past 4 weeks? * poorly controlled somewhat controlled not controlled completely controlled well controlled 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 list what you feel triggers your asthma symptoms? Do you have an asthma management plan? * yes no Are you confident on what you need to do in an emergency yes no In the last 12 months, have you needed antibiotics or steroids for exacerbation of your asthma? * yes no