Asthma Consultation e-form

Asthma Consultation e-form
Patient Information
NHI*
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town*
Informed consent | Healthify
Patient Consent*

Patient/Caregiver understands and agrees to participate in this service and consents for the pharmacist to access relevant medical records and share relevant information with other healthcare providers. They agree that anonymised data may be used to improve this service.
Consultation Data
Patients' understanding of their Asthma *
Use + to enter 1-5 (1 = Poor, 5= Excellent)
Patients' understanding of their Inhalers *
Use + to enter 1-5 (1 = Poor, 5= Excellent)
# of Salbutamol inhalers dispensed in last 12 months? *
Only prescribed Salbutamol*

YESNO
# of Hospital admissions for asthma in last 12 months? *
# of oral steroid courses dispensed in last 12 months? *
Has the patient got a current Asthma Action Plan?*

YESNO
Correct Inhaler Technique?*

YESNO
Referred to GP? Why?*

No referralPoor AdherencePoor controlRequires preventerRequires alternative deviceExcess use of salbutamolOther
Consultation Actions:*

No additional actionsSpacer providedSmokers at home - offered cessation adviceDiscussed vaccinationsHealthy Homes referralOther
Additional Clinical Notes (Voluntary)
Pharmacist Declaration
Pharmacy Name *
Choose from drop down list, or type to find name
Pharmacist Full Name*

First NameLast Name
Pharmacy Dispensary Email*
Pharmacist Declaration*

I agree that I have explained the consent process to the patient and I have conducted a comprehensive consultation utilising the "MidCPG Asthma Consultation Checklist"
Pharmacist Signature*

Clear
Date of Consultation *

DayMonthYear
Free type or use calendar (Backdating lock enabled > 10 days)
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Patient Full Name (REMOVE via PETE 15/12/2025)*

First NameLast Name
Should be Empty:

Asthma Consultation e-form

Patient Information

Consultation Data

Pharmacist Declaration

Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.