Asthma Review Please click on the Submit button to submit the form details. * indicates required fields    *Forename:   *Surname:   *Date of Birth:   *How often do you use your reliever (bue) inhaler?: Never Less than once a day Once or twice a day More than twice a day Not sure what this inhaler is   *How often does your asthma bother you daytime?: Never Once or twice a month Once or twice a week Every day   *How often does your asthma bother you at night?: Never Once or twice a month Once or twice a week Every night   *How often does your asthma bother you at exercise?: Rarely Only on active exercise / play Walking up hills or stairs Walking on the flat   *Do you ever forget to take your preventer inhaler?: No Yes Not sure what this is   *When do you use your preventer inhaler?: Daily Occasionally Not sure what this is   *Do you smoke?: Ex-smoker Yes No   *If you smoke would you like help to quit?: Not applicable No Yes   Anything else you want to tell us?:   *Contact e-mail: Please click on the Submit button to submit the form details.

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