Asthma prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Please share your birth gender *

Male
Female

2. Please note this service does not replace any physical asthma reviews. Please answer all questions with honesty. If you are having breathing difficulties or believe you are having an asthma attack please seek urgent medical attention, as this service is not suitable for you. *

I understand

3. Have you been diagnosed with asthma by your GP? *

Please share when you were diagnosed with asthma *

Within the last year
1-5 years ago
6-10 years ago
10+ years ago

4. What can we help you with today? *

I need to replace my inhaler
I would like a spare inhaler
I want to replace a lost/stolen inhaler
My child needs an inhaler
Other

This service is not suitable for you!

Please share more information with us *

5. Have you been prescribed this particular inhaler before? *

6. When were you last prescribed this inhaler? *

Less than 18 months
more than 18 months

7. What dosage were you prescribed to take ? *

8. Have you been prescribed an inhaler previously? *

Yes (blue inhaler- also known as a reliever)
Yes( blue, red, purple also known as a preventer)
Another type of inhaler
No

9. How many blue inhalers (relievers) have you used in the last 12 months? *

1 - 2
3 - 4
5 +
None

10. Do you currently take any other treatments/medications for your asthma? *

Please share more information with us *

11. We need to ask some clinical questions about your asthma. In the last few weeks (month) how often have you felt breathless, wheezy, coughing and a tight chest? *

Never
Less then 3 days a week
More than 3 days a week

We advise you speak with your GP or a nurse regarding your asthma. Based on the answers provided, it seems that your asthma is not under control and this could lead to an asthma attack. *

I understand

12. Over the last few weeks (month) how often has your asthma woken you up? *

Never
1-2 nights a week

We advise you speak with your GP or a nurse regarding your asthma. Based on the answers provided, it seems that your asthma is not under control and this could lead to an asthma attack. *

I understand

13. Over the last few weeks (month) when have you needed to use your blue inhaler (reliever) *

Never
Less than 3 days a week
More than 3 days a week

We advise you speak with your GP or a nurse regarding your asthma. Based on the answers provided, it seems that your asthma is not under control and this could lead to an asthma attack. *

I understand

14. Over the last few weeks (month) has your asthma affected your ability/capacity to exercise *

15. We now need to know your history with asthma. In the last year have you had any of the following *

Take steroid tablets
Go to A&E
Stay in hospital
None

Please share more information with us *

16. Have you ever had to be taken to ICU for severe asthma? *

17. When did you have your last physical asthma review? *

Less than 1 year ago
More than 1 year ago
I have never had a review

18. Please be aware, that our clinical team may feel more comfortable advising you to attend a physical review. We may not be able to prescribe you an inhaler, and this is at our clinical team's discretion. *

I understand

19. Please tell us about your general health. Do you have any of the following? *

Heart problems
High blood pressure
COPD
Diabetes
Overactive thyroid
Low potassium levels
Depression
TB
None

20. Other than what has already been discussed, do you have any other health issues , conditions or hospital stays you would like to share *

Please share more information with us *

21. Do you take over the counter prescription medications/recreational drugs or alternative medications? *

Please share more information with us *

22. Do you have allergies? *

Please share more information with us *

23. Are you pregnant or breastfeeding? *

24. Do you smoke? *

25. Are you overweight? *

26. Does a blue inhaler (reliever) inhaler improve symptoms long term? *

27. A blue inhaler (reliever) offers quick relief from symptoms. A brown inhaler (preventer) can be used every day and can treat asthma long term. *

I understand

28. Is there anything else you would like to share? *

Please share more information with us *

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Asthma