Asthma

Are you aged between 18 and 65? *

Have you been diagnosed with a respiratory condition, such as asthma or COPD, by your GP or another specialist clinician, and previously prescribed salbutamol? *

How often do you use your blue inhaler (e.g., Ventolin or salbutamol)? *

Have you received more than one salbutamol inhaler in the past 3 months, and more than three salbutamol inhalers in total in the past 12 months? *

Do you use a spacer with your inhaler (if recommended)? *

Do you know how and when to use your inhaler? *

Have you ever had an allergic reaction or adverse response to Ventolin (salbutamol) or any other inhaler? *

During the last 4 weeks, how much of the time has your asthma kept you from getting as much done at work, school or home? *

During the last 4 weeks, how often have you had shortness of breath? *

During the last 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning? *

During the last 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as Salbutamol)? *

How would you rate your asthma control during the last 4 weeks? *

Have your asthma symptoms worsened despite using your inhaler? *

Have you had any asthma/COPD attacks or flare-ups in the past year? *

Have you needed oral steroids, urgent GP visits, or hospital treatment for your symptoms in the last year? *

Are you using any other inhaler or regular preventer (usually brown, orange, or purple) inhaler or combined inhaler? *

How often are you using your preventer inhaler? *

Do you currently smoke? *

What tends to trigger your symptoms? (Tick all that apply) *

Do you have any of the following medical conditions? *

• Overactive thyroid (hyperthyroidism)
• Uncontrolled high blood pressure
• Heart rhythm problems (e.g., irregular or fast heartbeat, angina, susceptibility to prolonged QT interval)
• Hypokalemia (low level of Potassium)

Are you taking any of the following medications? *

• Beta-blockers (e.g., propranolol, bisoprolol)
• Digoxin
• Amiodarone
• Diuretics (e.g., furosemide, bendroflumethiazide)
• Steroid tablets (e.g., prednisolone)
• Theophylline / Uniphylline / Aminophylline
• Terbutaline (Bricanyl)
• Injectble biologic treatments (e.g., Fasenra, Dupixent)
• Recreational drugs

I understand that this is not an emergency service for respiratory issues, and that in the event of severe shortness of breath, wheezing, or chest tightness, I should seek immediate help by calling 999. *

I understand I must seek urgent medical attention if: *

• My asthma does not improve within 1 hour of using my inhaler
• I need more than 8 puffs in 24hours
• An asthma attack does not respond to my usual medication

I understand that I should schedule a review as soon as possible with my usual GP or asthma nurse if: *

• My last review was over 12 months ago
• I do not have a personalised asthma action plan
• Have been prescribed more than three blue inhalers in the past 12 months

I understand I should book an urgent review with my usual GP if I experience any of the following; my respiratory condition has been worse than usual, my respiratory condition has been causing me to wake up at least one night each week over the last 4 weeks, I am using a reliever inhaler more than 3 times per week. *

I understand that this questionnaire and the inhaler supply are not a substitute for regular reviews and ongoing monitoring with my GP. *

Can we share this information with your General practitioner? Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records. *

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

Do you agree to the following? *

• The information I have provided is true and accurate to the best of my knowledge.
• The information I have provided will be used to determine if it is appropriate to supply medication.
• I understand that inaccurate information may result in a refusal to supply medication or supply of inappropriate treatment.

Do you agree to the following terms? *

• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about my own health