788-792 Whalley New Road, Blackburn, Lancashire, BB1 9BA

Tel: 01254 247 477

This Form is Currently Unavailable

There is currently a technical issue with this form.
We are doing all we can to correct this.
Please return at a later date, or, if urgent, contact the Practice.

Home Page

ASTHMA HEALTH REVIEW

Personal Details

Full Name: Date of Birth: Postcode:

Asthma Health Review

Are you currently using medication for asthma?

Yes

If not, when was the last time that you used your medication?

How many times a day do you use your reliever (salbutamol)?

If you have a peak flow meter, what is your expiratory rate? Please note: the best, i.e. the highest, of three attempts.

Do you use a spacer device with your inhaler?

Yes

Have you been admitted to hospital because of your asthma in the past year?

Yes

Daytime Symptoms

Limiting Activities

Disturbing Sleep

Smoking habits?

Smoker

Never Smoked

Ex-Smoker

General Comments:

Confirm your Location

I confirm that I am a patient at Brownhill Surgery, Blackburn, Lancashire.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

Send Your Request

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form

Essential pages

News
Out of Hours
Covid-19 Information
‍ Register with the Practice
‍ Make an Appointment
‍ Order a Prescription
GP Team