Asthma Questionnaire Full name Date of birth Phone number Please select the boxes below which correspond to your experience of asthma within the last 4 weeks Does your asthma limit your daytime activities either at work or at home? Severely Restricts Sometimes Restricts Restricts Not Limiting Never How often have you had shortness of breath? More than once a day Once a day 3-6 times a week Once or twice a week Not at all How often does your asthma disturb your pattern of sleep? Frequently Once a night Once a week Occasionally Never How often do you use your rescue inhaler or nebuliser medication during the day eg: Ventolin Most Days 1-2 times per week 1-2 times per month Daytime Symptoms Never How would you rate your asthma control Not controlled Poorly controlled Somewhat controlled Well controlled Completely controlled Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?): Please note that the details you give will be used to update your medical records. Consent for storing submitted data Consent for storing submitted data