Please complete your annual asthma questionnaire in order to assist your doctor in how your asthma doing.
Your UNIQUE code
This is the UNIQUE practice code sent to you by your surgery by SMS - if you are not sure please ring the surgery 02088819606
Your email address
In order to verify who you are please offer your email address
In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?
NORMAL: Asthma NOT disturbing sleep
Asthma disturbing sleep weekly
Asthma disturbing sleep frequently
Asthma causing night waking
Asthma disturbs sleep
In the last month, have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)?
NORMAL: Asthma NOT causing daytime symptoms
Asthma causing daytime symptoms 1-2 times per month
Asthma causing daytime symptoms 1-2 times per week
Asthma causing daytime symptoms on most days
In the last month, has your asthma interfered with your usual activities (e.g. housework, work/school, etc)?
NORMAL: Asthma NOT limited activities
Asthma limiting activities 1-2 times per month
Asthma limiting activities 1-2 times per week
Asthma limiting activities on most days
Asthma limiting activities on walking up hill or stairs
Asthma limiting activities on walking on the flat
Asthma limiting activities
Asthma inhaler techniques
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