Consultation

Inhaler

Are you experiencing any of the following? Experiencing an asthma attack, Struggling to breathe, Very fast heartbeat, Exhaustion, Dizziness and drowsiness, Fingers toes or lips are turning blue, Short and fast breathing, Severe coughing and wheezing, Tight feeling in the chest.	Yes No
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What is your date of birth?
Do you believe you have the mental capacity to make decisions about your own healthcare?
Do you have any other disease, disorder or medical problem that the prescribing doctor needs to know?	Yes No
Please provide more information
Do you have any allergies?	Yes No
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Are you pregnant, breast feeding or planning to get pregnant?	Yes No
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Are you currently taking any other medications?	Yes No
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Do you smoke or take any recreational drugs?	Yes No
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Is your asthma undiagnosed? (i.e. you have not been seen to by a GP or specialist in the past)	Yes No
Please provide more information
When was your last asthma review with a GP or a specialist?

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