Asthma review (children)

Form summary

Asthma control questions

Let the child answer the first 4 questions. If the child needs help reading or understanding the question, you may help, but let the child choose the response.

Complete the remaining 3 questions on your own without letting the child’s response influence your answers. There are no right or wrong answers.

The child should complete the following 4 questions

How is your asthma today? *

Very bad

Bad

Good

Very good

How much of a problem is your asthma when you run, exercise or play sports? *

It is a big problem, I cannot do what I want to do

It is a problem and I do not like it

It is a little problem but it is okay

It is not a problem

Do you cough because of your asthma? *

Yes, all the time

Yes, most of the time

Yes, some of the time

No, none of the time

Do you wake up during the night because of your asthma? *

Yes, all the time

Yes, most of the time

Yes, some of the time

No, none of the time

Complete the following 3 questions on your own

During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *

During the last 4 weeks, how many days did your child wheeze during the day because of asthma? *

During the last 4 weeks, how many days did your child wake up during the night because of asthma? *

Does the child use their blue inhaler (reliever) every day?

Yes

No

Not applicable

Since the child’s last review, have they had any asthma exacerbations?

Yes

No

An exacerbation is where their asthma symptoms get gradually or suddenly worse, their reliever inhaler is not helping and they need medical attention

Provide details about the asthma exacerbations

For example, how many exacerbations they have had and what happened each time

Does the child have any of the following triggers?

Select all options that are relevant to the child

Other asthma triggers

Is the child exposed to second hand smoke at home? *

Yes

No

Does the child have a personalised asthma action plan? *

Yes

No

Are you able to provide the child’s latest peak flow reading?

Yes

No

Latest peak flow reading *

l/min

Inhalers

Which types of inhaler does the child use?

Inhalers can help:

relieve symptoms when they occur (reliever inhalers)
stop symptoms developing (preventer inhalers)

Some people need an inhaler that does both (combination inhalers).

Watch a short video from Asthma UK to learn how to use your inhaler properly (opens in new tab)

Have you watched and understood the inhaler videos for the child? *

Yes

Yes, but I would like a further explanation

No

Height and weight

Height in metres *

For example, 1.75

Weight in kilograms *

For example, 60.6

More information

Is there anything you would like to discuss?

Yes

No

For example, about the child’s asthma, lifestyle, medication, support

Provide details about what you would like to discuss

Terms and conditions

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.