Child Asthma Review

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Child Asthma Review

Please complete your annual asthma assessment to monitor your child's asthma. This is to check your child's breathing and assess if their asthma is stable

** We need only 1 submission per YEAR unless you have been told by the surgery for more.
** Please provide us with your email so we can potentially email you your Child Asthma care plan

Your CHILD's Details

Please include your latest personal details so that we can contact you if necessary

Your CHILD's full Name *

Your CHILD's Date of Birth *

Please include the DOB in the form of DD/MM/YYYY i.e 01/01/1980

YYYY

Your or CHILD's MOBILE number *

If we need to contact you to clarify your answers especially if your asthma is poorly controlled

Your or CHILD's EMAIL address

If we need to contact you to clarify your answers especially if your asthma is poorly controlled

ASTHMA Questions

TRIGGERS: what triggers their asthma and choose one or more of them i.e. pollen, tobacco, exercise, cold air. *

No triggers

Asthma triggered by pollen

Asthma triggered by warm air

Asthma triggered by cold air

Asthma triggered by damp

Asthma triggered by animals

Asthma triggered by emotion

Asthma triggered by respiratory infection (colds)

Asthma triggered by dust

Asthma triggered by exercise

Asthma triggered by perfume

Asthma triggered by aspirin

Required

FH: Any Family History of Asthma *

No family history of asthma

Yes - Family history of asthma

Required

SMOKING: Does ANYONE smoke in the household? *

Please inform us of your smoking habits including not smoked, ex-smoker or current smoker. If you do smoke and want to stop please ring One for Haringey on 0208 885 9095 or visit: https://www.oneyouharingey.org/

No one smokes in the household

Someone smokes in household (exposed to tobacco smoking)

YOUR CHILD'S HEIGHT & WEIGHT

Please submit your child's height and weight below in order for us to update your child's records and calculate their expected peak flow

HEIGHT: Your child's height (cm) *

Please submit your child's height in centemetre (cm) i.e. 120cm

WEIGHT: Your child's weight (kg) *

Please submit your child's weight in kilograms (kg) i.e. 25kg

PEAK FLOW: If you have been given one please provide a reading

- Move the marker to the bottom of the numbered scale.
- Stand up straight.
- Take a deep breath. ...
- Hold your breath while you place the mouthpiece in your mouth, between your teeth. ...
- Blow out as hard and fast as you can in a single blow. ...
- Write down the number you get below

PEAK FLOW: Your child's peak flow check (L/min) *

Please submit your child's peak flow measurement i.e. 300 L/min only if you have a peak flow meter. If you do not have one and require it to complete this form please request from reception

Videos of how to use an Inhaler or Aerochamber

Please watch the videos below regarding how to use an inhaler or aerochamber. Poor technique may mean that the medication may not work as well

If you are using a blue inhaler more than twice a week regularly, having regular coughing at night, or symptoms worse on exercise you may need to seek advice.

Also if you find that your blue inhaler is not helping, or using every 4 hours and still short of breath or unable to complete sentences consider using your taking 10 puffs of your blue inhaler and seek advice 111

How to use an aerochamber with an inhaler

How to use an inhaler

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