Asthma feedback form

Asthma feedback form

University Health Service, Southampton
Thank you for following the link to this form to send us up-to-date information about your current asthma situation.

We can, for many of our patients, collect this information without needing to see you, so thank you for answering the following questions.

We will use the data to update your medical record.
Do you consent to using Jotform to collect this data. This form is GDPR compliant, EU-based & secure.*

Yes, I consentNo, I do not consent

Asthma feedback form

Current situation
Are you still suffering with asthma?

Yes, I still have asthmaNo, my asthma has fully resolved (I have no symptoms & use no treatment anymore)

Asthma feedback form

Your asthma medications
Please tell us which inhalers or drugs your CURRENTLY USING for your asthma (please do not include inhalers or drugs which you do not use normally)*

Asthma feedback form

Sleep
How many nights per week is your sleep disrupted by asthma?*

My sleep is not disrupted by asthma1 night per week2 nights per week3 nights per week4 nights per week5 nights per week6 nights per weekEvery night

Asthma feedback form

Day times
How many days per week do you have asthma symptoms during the day time?*

I do not have day time asthma symptoms1 day per week2 days per week3 days per week4 days per week5 days per week6 days per weekEvery day

Asthma feedback form

Exercise
Typically, on how many days per week is your ability to exercise affected by asthma*

My exercise is not impaired by asthma1 exercise day per week2 exercise days per week3 exercise days per week4 exercise days per week5 exercise days per week6 exercise days per week7 exercise days per weekI never exercise

Asthma feedback form

Asthma review
When did you last have a face-to-face review with a nurse or doctor about your asthma?*

Last weekLast monthWithin the last three monthsWithin the last six monthsWithin the last yearMore than a year agoI don't know

Asthma feedback form

Your previous smoking history
When did you start smoking*
Enter year
When did you stop smoking*
Enter year
Typically, how many cigarettes did you used to smoke per day?*
Enter number per day

Asthma feedback form

Your smoking history
When did you start smoking*
Enter year
Typically, how many cigarettes do you smoke per day?*
Enter number per day
Smoking, with or without asthma, is a very harmful activity. Please contact us if you need help giving up smoking.

Asthma feedback form

Review with a professional
At the moment, do you need to see a health care professional to discuss your asthma further?

NoYes, I need to see someone

Asthma feedback form

Organising review
To see someone, please call the surgery on (023) 8055 7531 and book an appointment.

Alternatively, use you personal online secure account to book an appointment at https://www.patientaccess.com/.