Diagnosing Asthma with peak flow online

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Please complete this questionnaire to assess if you have Asthma

We need only 1 submission per YEAR unless you have been told by the surgery for more

Peak flows can be used in children above the of 7 or adult

Required for this form *

Please confirm you have the following devices. If you HAVE BEEN TOLD to complete this form and do NOT have these (i.e. peak flow) then request from reception

Peak flow meter

Asthma inhaler (blue or pink)

Required

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

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