Asthma review questionnaire Full name*Your date of birth*In the last month/week, have you had difficulty sleeping due to your asthma (including cough symptoms)?*Not at all1-2 Nights a weekMost nights1. Have you had your usual asthma symptoms (eg cough, wheeze, chest tightness, shortness of breath) during the day?*No1-2 per month1-2 per weekMost daysHas your asthma interfered with your usual daily activities (eg school, work, housework)?*No1-2 per month1-2 per weekMost daysOn average approximately how many times a month do you use your reliever (ie salbutamol/terbutaline) inhaler?*Once a month2-3 times a month4 or more times a monthPlease select your current smoking status from the drop down list*Never smoked tobaccoEx SmokerCurrent SmokerReady/Thinking about stopping smokingWould rather not give smoking statusIf you are ready or thinking about stopping smoking for further information and support please visit our NHS Smokefree Support Service page which can be found under the Services heading on our main menu.