Summervale Surgery

Summervale Surgery

Canal Way, Ilminster, Somerset, TA19 9FE

Sorry, we're currently closed. Please call NHS 111

NHS

Telephone: 01460 52354

Out of Hours: 111

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Please note we are closed for training on the first Wednesday afternoon of each month from 1pm until 4pm.

 

Asthma Control Assessment Test

A member of the clinical team may ask you to complete this form prior to your Asthma review.
Name
DD slash MM slash YYYY
Question 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
Select one checkbox only
Question 2. During the past 4 weeks, how often have you had shortness of breath?
Select one checkbox only
Question 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
Select one checkbox only
Question 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
Select one checkbox only
Question 5. How would you rate your asthma control during the past 4 weeks?
Select one checkbox only
This field is for validation purposes and should be left unchanged.