Asthma questionnaire

PLEASE ENSURE YOU ANSWER ALL QUESTIONS WITH THE RED ASTERISKS*

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Your details
Asthma control test questions
 
 
 
 
 

 Your Asthma Control Test score (ACT) is:

Height and Weight
 
Body Mass Index (BMI):
 
BMI 20-25 - ideal range
BMI 25-30 - overweight
BMI > 30 - obese
A high BMI is associated with worsening symptoms of asthma including breathlessness and cough. It is imperative to have a healthy BMI to ensure good asthma control
Smoking

We can help you quit

The Lambeth stop smoking service has many ways to help you quit and is located at various sites throughout the Borough. The doctors at the surgery can also help you to quit, click the image on the right for further info.

                                                   

Medication
Using inhaled medication is not as simple as it may seem. There are all sorts of different inhalers and some of them will need to be used in a different way to others. If inhalers are not used with the correct technique, it is possible that the medication won't reach your lungs and you will suffer unwanted side effects. Please click on the link to view Rightbreathe and find your inhaler webpage. Then click on the video which will give you a demonstration on how to correctly use the inhaler.
If you use a metered dose inhaler (the inhaler that sprays out the medication when you press it) then using a spacer device (pictured opposite) will enable much better delivery of the medication to your lungs. Just check the boxes below and we will prescribe it for you with your next batch of inhalers (please note a spacer cannot be used with dry powder inhalers - these are the ones where you suck the medication out of the chamber).

Click here to visit www.rightbreathe.com

Please tick this box
Asthma exacerbations
Self management

                                                                                               

                                                                       Asthma UK self management plans

Asthma risk managment

Low risk Asthma - please select    ———————►

Your ACT score is 20 or more and you have had no asthma flare ups in the last year and you are not needing to use your blue reliever inhaler regularly. You are at LOW RISK with Asthma and require no changes to your treatment. A clinician will review this and only contact you if anything needs to be done.

Low risk Asthma with High Salbutamol use - please select    ———————►

Your ACT score is 20 or more and you have had no asthma flare ups in the last year BUT you seem to be using your blue reliever inhaler very frequently which can be a sign of poor asthma control and may require a change in your treatment. You seem to be at LOW RISK with Asthma  but we need to review the use of your blue inhaler as you may need a step up in your maintenance treatment to help reduce your reliance on the blue reliever inhaler. A clinician will review this and contact you.

Moderate risk Asthma - please select   ————►

Your ACT score is 15-20 and you've had less than 2 flare up(s) of Asthma in the last year. You may have needed to use the blue reliever inhaler up to a few times a week. This means you could be at MODERATE RISK with your Asthma. You will be contacted by a clinician to discuss any treatment changes that may be required.

ACT 15-19

Moderate risk Asthma - please select   ————►

Your ACT score is 15-25 and if you've had less than 2 flare up(s) of Asthma in the last year. You have needed to use the blue reliever inhaler up to a few times a week. This means you could be at MODERATE RISK with your Asthma. You will be contacted by a clinician to discuss any treatment changes that may be required.

ACT>20 + 1exac nonsmok
ACT>20 + 1 exac

Moderate risk Asthma - please select   ————►

Your ACT score is 15-25 and you've had less than 2 flare up(s) of Asthma in the last year. You may have needed to use the blue reliever inhaler up to a few times a week. This means you could be at MODERATE RISK with your Asthma. You will be contacted by a clinician to discuss any treatment changes that may be required.

ACT>20 + 0exac + smok

Moderate risk Asthma - please select   ————►

Your ACT score is 15-25 and you've had less than 2 flare up(s) of Asthma in the last year. You may have needed to use the blue reliever inhaler up to a few times a week. This means you could be at MODERATE RISK with your Asthma. You will be contacted by a clinician to discuss any treatment changes that may be required.

High risk Asthma - please select    ———————►

Your ACT score is less than 15 OR you've had more than 2 flare ups of Asthma in the last year OR have needed to use the blue reliever inhaler more than a few times a week OR you are a smoker, smoking more than 10 cigarettes per day. You are therefore at HIGH RISK with your Asthma. Please ensure you contact the practice to arrange review. You may be contacted by a clinician soon to discuss any treatment changes that will be required. Please ensure you take time to have this review as it is important to prevent escalation of breathing difficulties.

 

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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