Remote Annual Respiratory Review

If you have been asked to do so by the practice, please fill in this form.

Remote Annual Respiratory Review

Remote Annual Respiratory Review

Section

Health and Lifestyle

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.
Have you ever smoked? *
Do you smoke now? *

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what's right for you. For more information visit the Smokefree website.

Respiratory Review

Do you have asthma? *

Asthma

Since your last review, have you needed to see a Doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
How would you rate your asthma control during the past 4 weeks? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

If your score is 25+:

Well done

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

Asthma

Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Have you watched and understood the video(s)? *
Are you happy with your inhaler technique? *
Would you like further explanation from a practice nurse?
For more help with your inhaler technique, you can visit the Asthma UK website.

Do you have COPD? *

COPD

Over the last year, have you had any hospital admissions related to your COPD or required antibiotic or steroid treatment?
Have you ever been issued with a rescue pack or told by a clinician you require one?
If you use inhalers, do you feel they are helping with your symptoms and that you are happy with how to use them?
Do you measure your oxygen saturations at home?
Are you on home oxygen therapy?
As part of the MRC scale, please tick one of the below options to rate your breathlessness: *

The Pulmonary Rehabilitation Programme can be offered virtually to patients at present to help with managing all COPD/lung related symptoms and is run by the specialist rehabilitation respiratory team. Please see link here for more information: www.norfolkcommunityhealthandcare.nhs.uk/pulmonary-rehabilitation

Would you be interested in the pulmonary rehabilitation programme?

A referral will be made by clinicians and will be contacted in due course depending on availability.

Do you feel you are overall happy with your current management of your condition and with your medicines to help with your symptoms?

A telephone appointment will be offered to you.

*