Asthma Annual Review

Thank you for taking time to do your asthma review. Your review will be submitted to a member of our clinical team. It may take approximately 7 days before you will receive confirmation of your asthma review was accepted or whether you need follow up appointment.

Please note that this is annual review, and you will not be asked by us to fill this form more than once a year. However, if your symptoms change or you need further review of your medications please do not hesitate to contact us.

Please note that in some cases you may still be required to attend an appointment if the clinical staff feels that you may need further input into your clinical care.

This form may take you approximately 10 minutes to fill in.

Full name including middle name

Date of Birth

Mobile number

Email address

Home address including postcode

Medications

1. Asthma management medication currently taking

2. Asthma management medication currently taking

3. Asthma management medication currently taking

4. Asthma management medication currently taking

5. Asthma management medication currently taking

Clinical Information

Height

Weight

Blood Pressure (please use format 150/80)

Date Blood Pressure Taken

Daytime symptoms

Asthma limiting activities

Asthma disturbing sleep

Do you feel you need assistance in reviewing your inhaler technique (how well and effectively you use your inhaler each time)https://www.asthma.org.uk/advice/inhaler-videos/

Have you booked your FLU vaccination?Please note that the surgery orders large amount of FLU vaccinations for our patients. If all our eligible patients have vaccination with the surgery this enables us not waste of NHS money by not distributing them out but also helps us reinvest income from the FLU vaccinations to extend services provided at the surgery. However please note that it still remains patient's choice where you choose to have your vaccination.

Smoking status

Smoking cessation Please note that if you are interested to pursue stopping smoking, the surgery nurses can support you on your journey to become a non-smoker. We will contact you to get you on the right track.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Phoenix Family Care (GP Surgery in Coventry) • 103 Leamington Road, Coventry, CV3 6GQ .

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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