Asthma Peak Flow Readings

Step 1 of 6

16%

Who are you completing this form for? RequiredFor example, on behalf of a child or dependent

Yourself

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What is the patients postcode? Required

What is your relationship to the patient? Required

Parent

Guardian

Spouse

Carer

Son

Daughter

Sibling

Other

What is your name? Required

First Last

What is your date of birth? Required

Day

Month

Year

What is your sex? Required

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Female

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What is your phone number? Required

What is your email address? Required

Week 1

Day 1

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 2

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 3

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 4

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 5

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 6

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 7

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Week 2

Day 1

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 2

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 3

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 4

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 5

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 6

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 7

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Week 3

Day 1

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 2

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 3

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 4

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 5

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 6

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 7

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Week 4

Day 1

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 2

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 3

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 4

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 5

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 6

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

Day 7

Symptoms OptionalPlease tick any which may apply

Used reliever inhaler

Had asthma symptoms such as shortness of breath, tight chest, coughing or wheezing

Waking at night with asthma symptoms

Feeling like you can’t keep up with your normal day-to-day activities

AM Reading Required

PM Reading Required

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Asthma Peak Flow Readings

Week 1

Week 2

Week 3

Week 4

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