Regent Gardens Medical Centre > Forms > Electronic Reviews > Asthma Review Form

Asthma Review Form

Asthma Review
Enter Email
Please use format day/month/year e.g. 12/05/1979

Your Asthma Review

How many days a week do use your reliever (blue) inhaler *
Have you had difficulty sleeping because of your asthma? *
Has your asthma interfered with your usual day to day activity? *
Have you been admitted to hospital in the last 12 months? *
Do you think you need to change your medication? *
Do you smoke? *
We will be in contact with you in the next two weeks. How would you like us to contact you? *
One of our clinicians will contact you on this number in the next couple of weeks.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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