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Asthma Assessment

Asthma Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Asthma Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you been prescribed reliever inhalers before?*

Yes

No

Please provide more information below.*

Have you had an asthma review in the past 12 months and provided with an asthma plan? Asthma reviews will include checking that you are able to: Measure your peak flow and user your inhaler correctly.*

Yes

No

Please provide more information below.*

Are you aware you should schedule a check-up with your usual asthma GP or nurse specialist if any of the following apply: • Using your Salbutamol (Ventolin) inhaler more than 3 times a week or more • Experiencing symptoms of asthma 3 times per week or more • Waking in the night due to asthma symptoms once per week or more • You develop symptoms such as a night cough or uncontrolled shortness of breath. • Experienced an acute asthma attack within the last 2 years.*

Yes

No

Please provide more information below.*

Do you use more than one salbutamol inhaler every month?*

Yes

No

Please provide more information below.*

Are you taking any other inhalers, tablets or prescription medicine for your asthma?*

Yes

No

Please provide more information below.*

Health

Have you ever been hospitalised or had to visit the A&E due to your asthma?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Does your asthma wake you up at night?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you currently taking any other prescription medications or recreational drugs?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you suffer from any heart conditions including angina and problems with heart rhythm?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Other than those already mentioned do you have any other significant medical conditions, illnesses or past surgical procedures?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant or planning to become pregnant within the next six months or breastfeeding at the moment?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you been advised to avoid strenuous exercise, or do you have difficulty in walking for more than 5 minutes at a fast pace?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do You Smoke?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to ensure that any prescribed Asthma Treatments are both effective and safe for the patient, considering their current health status and potential exposure to malaria.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Name

This field is for validation purposes and should be left unchanged.

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