Disclaimer - Asthma Consulation Form

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?

What is your Date of Birth?

Day

Month

Year

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Do you suffer from any allergies?Yes | No

If Yes Give Details

Have you had any Asthma treatment before? Yes | No

If Yes Give Details

Have you had any Asthma treatment before? Yes | No

If Yes Give Details

Has a doctor or nurse diagnosed you with asthma?

When was your last asthma review? (approx date) Yes | No

If Yes Give Details

Is your asthma well under control?

During the last 4 weeks, how much of the time has your asthma kept you from getting on with normal day to day activities at work or home?

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

During the last 4 weeks, how often have you used your reliver inhaler such as Salbutamol?

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?

Have you had emergency treatment for breathing problems, or needed to call an ambulance in the last year?

How many issues on ventolin have you had in the last 12 months from either a GP or online purchases? Please state

Have you been diagnosed by a medical professional with any health conditions?

Have you had a diagnosis of the following? Overactive thyroid gland Cardiovascular disease Arrythmias,Susceptibility to prolonged QT-interval Hypertension Hypokalaemia Hyperthyroidism History of heart problems such as an irregular or fast heartbeat

Are you taking any of the asthmatic treatments below?

Please specify other asthma medication

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

If your asthma does not improve within 1 hour of using your inhaler, please confirm that you must seek medical attention.

Do you agree to watch the following video on correct inhaler techniques? https://www.asthma.org.uk/advice/inhaler-videos/pmdi/

You have answered all the above questions as truthfully and accurately as possible. Our prescribers take your answers in good faith and base their prescribing decisions accordingly, and if you have inputted incorrect information it can be hazardous to you

Would you like us to inform your GP?

To continue, please provide your GP's surgery address below.

Please confirm the below; I confirm I am aware how to use my inhalers. I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects.

Product

1 Ventolin Inhaler£7.49

2 Ventolin Inhaler£14.49