Do you know how and when to use your inhaler?

GP Surgery Name

GP Surgery Address

Have you called an ambulance or had emergency treatment for breathing problems in the last year?

Do you use your inhaler more than four times a day?

Have you been diagnosed with asthma by your doctor or nurse?

Has your Asthma been reviewed by a doctor or nurse within the last 12 months?

Have you been prescribed Ventolin (salbutamol) in the last 12 months?

Is your asthma well controlled?

If you are not sure take the asthma control test here.

Do you have an allergy (hypersensitivity) to Ventolin (salbutamol) or have you had a reaction with an asthma inhaler previously?

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Have you been diagnosed with any of the following?

• Overactive thyroid gland
• History of heart problems such as an irregular or fast heartbeat or angina
• High blood pressure
• Any serious medical condition which may require immediate hospitalisation

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Do you understand that you must seek medical attention if your asthma does not improve within 1 hour of using your inhaler?

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• I agree to do a video consultation for the supply of this medication.