How did you hear about us?
I confirm the above statements are true --This service is not suitable for urgent asthma, COPD or breathing problems--If you are struggling with your breathing, having an asthma attack or have any chest pains or discomfort call 999 and go to A+E immediately--A patient with well controlled asthma experiences; symptoms less than 3 times a week during the day, no symptoms during activity or exercise, no symptoms at night and a reliever inhaler would last between 4-6 months before running out--We will notify your GP about the outcome of your consultation to ensure safe ongoing care.--We may give advice on either stepping up or stepping down your asthma treatments based on asthma guidelinesThis questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service:--I am 18 years old or above.--I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.
We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.
What is your sex?
What is your date of birth?
Has a clinician previously prescribed Ventolin (salbutamol) to you?
Why do you use a Ventolin inhaler?
Please tell us do you feel confident in using your inhaler? When was your last asthma review? Do you know why your condition got so bad? Have you ever spent the night in hospital because of asthma? And when was the last time this happened? Were you treated in the Intensive Care Unit (ICU)? Have you ever had a course of steroid tablets (prednisolone) for your asthma, usually it’s a five or seven day course? How long does a salbutamol inhaler last you from start to finish? Are you currently experiencing any symptoms of a chest infection or an exacerbation of your asthma? In the past four weeks, how much of the time did your asthma keep you from getting as much done at work, college or at home? During the past four weeks, how often have you had shortness of breath? During the past four weeks, how often have you used your reliever (blue/ ventolin) inhaler? How would you rate your asthma control during the past four weeks? Which of the following affect your asthma? Certain jobs are also known to affect asthma. Do you do any of the following jobs? Do you notice that your asthma is better on days that you do not work? Have you been admitted to hospital because of your COPD or other respiratory problem within the last five years? Please give full details of your hospital admissions. Please provide details about why you use your Ventolin inhaler
Roughly how many Salbutamol inhalers have you used in the last 12 months?
Have you ever needed an emergency nebuliser from your GP or in hospital?
Please tell us when was have you ever needed an emergency nebuliser from your GP or in hospital? And do you know why your condition got so bad?
Please enter your height(cm).
Please enter your weight(kg).
Are you taking any other inhalers or tablets for your condition?
Please give more details
Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?
In the last two months have you taken any medicine, including both prescription and non-prescription medicines, other than any medicine you have mentioned above?
Are you allergic to any of the following? Please select all that apply.
Do you have any other known allergies?
Please give details of all your allergies
Do you or have you ever suffered from any heart conditions including angina and problems with heart rhythm?
Have you ever had Tuberculosis (TB) in your lungs?
Do you suffer from any of the following?
Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?
How do I know if I\'m pregnant?
Are you breastfeeding?
Do you smoke?
I confirm the above statements are true --I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Youth and Earth Labs Online Doctor before proceeding--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.--I have read, understand and agree to the latest terms and conditions and privacy policy.
