Asthma Consultation e-form

Asthma Consultation e-form
NHI*
Patient Full Name*

First NameLast Name
Date of Birth*

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

I understand and agree to participate in a consultation with my Pharmacist. I consent to my pharmacist accessing relevant medical and hospital records to support my health care. I agree that anonymised data may be used to improve the service.
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? *
Correct Inhaler Technique*

YESNO
Has the patient got a current Asthma Action Plan?*

YESNO
Consultation Actions:*

No additional actionsSpacer providedSmokers at home - offered cessation adviceDiscussed vaccinationsHealthy Homes referralOther
Referred to GP? Why?*

No referralPoor AdherencePoor controlRequires preventerRequires alternative deviceExcess use of salbutamolOther
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Email*
MUST be completed to receive copy of PDF for pharmacy records
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
Signature*

Clear
Date of Consultation *

DayMonthYear
Free type or use calendar date picker
DOCUMENT VERSION CONTROL: Asthma Consultation Form V1.0

PT NAME field hidden 15/12 as per Pete Chandler
Should be Empty: