| Contact Details |
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| Questionnaire |
| 1. When was your asthma diagnosed? |
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| 2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)? |
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| Details of sleeping difficulties: |
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| 3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? |
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| Details of symptoms during the day: |
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| 4. How often do you use your blue inhaler? |
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| Details of inhaler use: |
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| 5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)? |
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| 6. If you have a peak flow metre, please put in most recent measurement. |
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| 7. Are you happy with your inhaler technique? |
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| 8. Are you a smoker ? |
No |
Yes |
| 9. Would you like smoking cessation advice? |
No |
Yes |
| Auchtermuchty Health Centre recommends that giving up smoking is the best thing you can do to improve your own health and can offer you personalised smoking cessation advice and treatment. |
| If you are not, did you know there is an online demonstration on the Asthma UK website or pop in and see our practice respiratory nurse for more advice. |
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