Asthma Questionnaire Full Name Date of Birth Day Month Year 1. Are you experiencing your usual asthma symptoms during the day? If so, how often? Optional 2. Is your asthma disturbing your sleep? If so, how often?: Optional 3. Does your asthma limit your everyday activities (eg school, employment, housework)? Optional 4. Are you using your blue/reliever inhaler more than once a day (eg Salbutamol/Terbutaline)? If so, how many times on average? Optional 5. If you undertake peak flow monitoring, please provide your last reading. Optional 6. Do you smoke? This question applies to anyone over the age of 14 years.) Optional We strongly advise against smoking. For professional help to stop smoking please contact The Quit Squad on 0800 328 6297 to get a local appointment or see The NHS Quit Squad Website
