Asthma Assessment Tool Please read our terms and conditions before proceeding with this assessment tool. Asthma Assessment Step 1 of 4 25% Have you been diagnosed with Asthma?*YesNoThis assessment is for patients diagnosed with Asthma. If you have not yet consulted your doctor in relation to your breathing symptoms, please contact 07 3267 5088 to speak with one of our receptionists or book an appointment online to discuss this with your doctor further. Asthma Severity AssessmentDuring the past 4 weeks:How often did your asthma prevent you from getting as much done at work, school or home?*All the timeMost of the timeSome of the timeA little of the timeNone of the timeHow often have you had shortness of breath?*More than once a dayOnce a day3-6 times a week1-2 times a weekNot at allHow often did your asthma symptoms wake you at night or earlier than usual?*4 or more times a night2-3 times a nightOnce a nightLess than once a weekNot at allHow often have you used your blue puffer or reliever medication?*3 or more times a day1-2 times a day2-3 times a weekLess than once a weekNot at allHow would you rate your asthma control?*Not controlled at allPoorly controlledSomewhat controlledWell controlledCompletely controlledAsthma Assessment Score Are you on a preventor medication? (Eg Seretide, Flixotide, Symbicort, Alvesco)*YesNoDo you have an up to date (Within the last 12 months) Asthma Action Plan?*YesNoAdmin Use Only Result - Asthma Control is Good!Congratulations! Your asthma control is good! However, flare up of asthma symptoms may still occur, so please ensure you always have a reliever puffer available and that it has not expired. If you have a flare up or require a script for your puffers, please book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Preventer Regime is working and your Asthma Control is Good!Congratulations! Your asthma control is good and you have an up to date Asthma Action Plan! However, flare up of asthma symptoms may still occur, so please ensure you always have reliever and preventer puffers available and that it has not expired. If you have a flare up or require a script for your puffers, please book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Asthma Control could be better, and you may benefit from a Preventer Puffer and an updated Action Plan.According to your assessment, you are having frequent asthma symptoms, and you may benefit from a preventer puffer and an up to date Asthma action plan to help reduce your asthma symptoms. If you would like to discuss this result further with our team, please enter your contact details and click the submit button below to send us a copy of your test result, and our Asthma Nurse will contact to you to arrange an appointment suitable for you. Otherwise, you can also book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Asthma Control could be better, and you may benefit from a Preventer Puffer and an updated Action Plan.According to your assessment, you are having frequent asthma symptoms, and you may benefit from a preventer puffer and an up to date Asthma action plan to help reduce your asthma symptoms. If you would like to discuss this result further with our team, please enter your contact details and click the submit button below to send us a copy of your test result, and our Asthma Nurse will contact to you to arrange an appointment suitable for you. Otherwise, you can also book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Asthma Control could be better, and you may benefit from a change in your puffer medications and an updated Action Plan.According to your assessment, you are having frequent asthma symptoms, and you may benefit from a change in your preventer puffer and an up to date Asthma action plan to help reduce your asthma symptoms. If you would like to discuss this result further with our team, please enter your contact details and click the submit button below to send us a copy of your test result, and our Asthma Nurse will contact to you to arrange an appointment suitable for you. Otherwise, you can also book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Asthma Control could be better, and you may benefit from a change in your puffer medications and an updated Action Plan.According to your assessment, you are having frequent asthma symptoms, and you may benefit from a change in your preventer puffer and an up to date Asthma action plan to help reduce your asthma symptoms. If you would like to discuss this result further with our team, please enter your contact details and click the submit button below to send us a copy of your test result, and our Asthma Nurse will contact to you to arrange an appointment suitable for you. Otherwise, you can also book online or ring 07 3267 5088 to make an appointment with your Doctor.Result - Your Asthma Control is good, but you may benefit from an up to date Asthma Action Plan.According to your assessment, your asthma control appears to be good. However, it is recommended that patients on preventer puffers have a yearly asthma assessment and up to date Asthma Action Plan. If you would like to discuss this result further with our team, please enter your contact details and click the submit button below to send us a copy of your test result, and our Asthma Nurse will contact to you to arrange an appointment suitable for you. Otherwise, you can also book online or ring 07 3267 5088 to make an appointment with your Doctor.Name* First Last Best Contact Phone Number*Email Consent to Submit Assessment* I agree/ consent to submit the above Asthma Assessment Result to Banyo Clinic, and for Banyo Clinic to contact me for further follow up in relation to this result.
