Asthma questionnaire
Please complete your annual asthma questionnaire in order to assist your doctor in how your asthma doing

**We need only 1 submission per YEAR unless you have been told by the surgery for more
Your Details
Please include your latest personal details so that we can contact you if necessary
Your Full Name *
Your Date of Birth *
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
Your MOBILE number
If we need to contact you to clarify your answers especially if your asthma is poorly controlled
Your EMAIL address
If we need to contact you to clarify your answers especially if your asthma is poorly controlled
Asthma Questions
SLEEP: In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? *
DAYTIME: In the last month, have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? *
ACTIVITIES: In the last month, have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? *
Other health information
SMOKING: Do you smoke? If so how many? *
Please inform us of your smoking habits including not smoked, ex-smoker or current smoker. If you do smoke and want to stop please ring One for Haringey on 0208 885 9095 or visit: https://www.oneyouharingey.org/
Captionless Image
ALCOHOL: Do You drink? How many units in a week? *
1 pint of beer is approximately two units and one small glass of wine is 1 unit
Captionless Image
Submit
Never submit passwords through Google Forms.
This form was created inside of west green surgery. Report Abuse