The Crouch Oak Family Practice
45 Station Road Addlestone KT15 2BH - Tel: 01932 840123

ANNUAL ASTHMA QUESTIONNAIRE

If you use inhalers regularly for your Asthma, we need you to tell us once a year how Asthma affects your daily life.  Please complete the questionnaire below and click submit.  Your answers will be recorded on your clinical record.

NOTE: You can save your details and automatically populate this form by creating an account.
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Asthma Questionnaire

Asthma Questionnaire

If you use inhalers for your Asthma please use this form to tell us your daily life is affected by Asthma

  • / /
    Pick a date.
  • Please answer this question with reference to when you are well

  • Select the answer that applies when you are well

  • Please give the name of the medication and the number of puffs per day that you usually have

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