Friendly, efficient healthcare

Asthma online questionnaire

Please complete the following questions to allow your health care professional to assess your asthma.
This questionnaire is for a routine review of your symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately

Asthma Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Asthma review

  • Please enter a number from 0 to 999.
  • Please enter a number from 0 to 999.
  • Further Questions

  • When you are happy with all of your above answers, please click 'Submit' below and the questionnaire will then be automatically sent to your Asthma Nurse or Doctor.