Waterside Health Centre

The Red and Green Practice

Waterside (Hythe) and Blackfield Health Centres

Southampton

Partners in the Primary Care Network (PCN)

Blackfield Health Centre

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Form Title Here

1. In the last month/week have you had any difficulty sleeping due to your asthma (including cough symptoms)?

1-2 times a month

1-2 times a week

Daily

2. Have you had your usual asthma symptoms (eg. cough, wheeze, chest tightness, shortness of breath) during the day?

1-2 times a month

1-2 times a week

Daily

3. Has your asthma interfered with your usual daily activities (eg, school, work, housework)?

1-2 times a month

1-2 times a week

Daily

Please ensure we have the correct contact details on record for you:

May we send you text messages about your care?

Yes

May we send you emails about your care?

Yes

(For 18yrs+) If you have a home BP machine, please enter a BP Reading below:

(For 18ys+) If you do not have a home BP machine, please select one of the following options:

I will call into the Surgery to take my BP

I have already handed my BP reading in recently (after 1st April)

I do not wish to have my BP taken at this time

Please tick this box before submission to acknowledge that this form is being sent un encrypted via the world wide web

The information you have completed in this form will be stored in the Wix Website Editing Software, which is accessed using the practice's Wix login via the world wide web, please tick this box to confirm you are happy for this information to be stored.

If you are not happy to tick the boxes above please write down your details as requested above and return it to the surgery.

Thank you for submitting. We will update your record with your answers