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Asthma review (adults)

Asthma Review
Required fields are labelled
You must be aged 13 or over to complete this form yourself

Your Information

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Section

In the last month have you had difficulty sleeping due to your asthma (including cough)?
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day?
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)?