Asthma Review under 12s

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Personal Details

If you have been advised by the surgery to submit an annual review of your child's asthma symptoms, please use this form. If their symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

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Asthma Control Test

How to answer the childhood asthma control test

Let your child answer the first four questions.  If your child needs help reading or understanding the question, you may help, but let your child choose thier response.

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These three questions are to be completed by the parent/guardian/carer:

Complete the remaining three questions on your own without letting your child's response influence your answers.  There are no right or wrong answers.

Your Score

Off Target

You scored 

If your child's score is 12 or less, thier asthma may be very poorly controlled during the past 4 weeks.
Your Doctor or Nurse may recommend an asthma action plan to help improve your child's asthma control once you have submitted this form.

On Target

You scored 

Your child's asthma may not have been as well controlled as it should be during the past 4 weeks.
Your Doctor or Nurse may recommend an asthma action plan to improve this.

Well Done

You scored 

Your child's asthma appears to have been under control over the last 4 weeks.
However, if your child is experiencing any symptoms or you have any queries, please add these into the comments box at the end of this form.

 
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Additional Questions

Additional Questions

Please complete the additional questions below and then press submit to send your review to your Doctor.

How to get an asthma action plan

If you’re not using an asthma action plan yet, it’s easy to get started:

  1. Download an asthma action plan here. If you can, print out a copy to take to your GP or asthma nurse.
  2. Book an asthma appointment with your GP or asthma nurse.
  3. At the appointment, talk through the plan with your GP or asthma nurse and fill it in together. You can do this by telephone or video call too if your appointment isn’t in the surgery. Ask them to save a copy onto your notes and send it to you on email, SMS or WhatsApp.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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