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Stewarton Medical Practice
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Stewarton Medical Practice
Menu
Home
About Us
History
Contact
Have your Say
Location
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Sick/Fit Note
Forms
Keep us up to Date
Electronic Reviews
New Patient Registration
Help & Support
News
Stewarton Medical Practice
>
Forms
>
Electronic Reviews
>
Asthma Review Form
Asthma Review Form
Asthma Review
First Name
*
Last Name
*
Email
*
Enter Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Your Asthma Review
How many days a week do use your reliever (blue) inhaler
*
1
2
3
4
5 or more
Have you had difficulty sleeping because of your asthma?
*
Yes
No
Has your asthma interfered with your usual day to day activity?
*
Yes
No
Have you been admitted to hospital in the last 12 months?
*
Yes
No
How would you rate you asthma control?
*
1 Star
2 Stars
3 Stars
4 Stars
5 Stars
Do you think you need to change your medication?
*
Yes
No
Do you smoke?
*
Yes
No
We will be in contact with you in the next two weeks. How would you like us to contact you?
*
Telephone Consultation
Video Consultation – requires smartphone, tablet or PC with webcam
Phone Number to contact you
*
One of our clinicians will contact you on this number in the next couple of weeks.
The practice will be in contact. Any comments you would like to add?
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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Home
About Us
History
Contact
Have your Say
Location
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Sick/Fit Note
Forms
Keep us up to Date
Electronic Reviews
New Patient Registration
Help & Support
News