Western Road Medical Centre

99 Western Road, Romford, Havering, RM1 3LS

Telephone: 01708 775300

nelondonicb.westernroad@nhs.net

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Asthma assessment for Children Before 12th birthday

Please use this page to submit information in preparation for your telephone review. This will help us carry out the reviews more efficiently and be better able to focus on any areas of your asthma care that require more attention. Click submit at the end of the form – this will send us a secure email which we can then use to transfer the information to your records.

We appreciate this form may take a bit of time to go through – we have tried to keep it as brief as possible and anticipate that most people should be able to complete it within 10 minutes. If the patient is a child and/or not able to fill it in, please fill it in on their behalf.

Asthma Questionnaire for Children (3-11years)

  • MM slash DD slash YYYY
  • *CHILDREN ONLY* TYPE N/A IF NOT APPLICABLE TO YOU
  • Please include visits to GP, walk-in clinic, urgent care centre, A+E, and hospital admissions. If you are not sure exactly, give an approximation.
  • Give an approximation if you are not sure.
  • Give an approximation if you are not sure.
    Please see the following guidance on hygiene: https://www.nhs.uk/live-well/healthy-body/best-way-to-wash-your-hands/ and tick the above box to confirm understanding
    Please see the following guidance on social distancing https://www.nhs.uk/conditions/coronavirus-covid-19/social-distancing/what-you-need-to-do/ and tick the above box to confirm understanding
  • Please select which one describes you best.
    If you are a smoker currently, please look at the following information https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/ and tick above if you wish pursue efforts to stop smoking
  • Max. file size: 128 MB.
    If you are in possession of a self-management plan, then please scan and attach it here if you are able to.
  • Please indicate if you have had the flu jab since the most recent September
  • Please indicate here if you recall having had this (usually one-off vaccination)
    What triggers your symptoms? Tick all that apply
  • Please enter a number from 0 to 1000.
    If you do not have peak flow or know how to use one, please ask your doctor or nurse and look at the following information https://www.asthma.org.uk/globalassets/health-advice/resources/adults/your-peak-flow-diary.pdf
  • Please enter a number from 0 to 1000.
  • If you have more than one device the please provide a description for each type of inhaler.
  • We will ask you to describe your inhaler technique over the phone. Studies suggest that only 10% of patients use their inhaler correctly. Please refer to the following resource for further information https://www.asthma.org.uk/advice/inhaler-videos/
  • Ask your child to answer this question.
  • Ask your child to answer this question.
  • Ask you child to answer this question.
  • Ask your child to answer this question.
  • Give your best guess if you are not sure exactly
  • Give your best guess if you are not sure exactly
  • Give your best guess if you are not sure exactly
    Please refer to this guidance to confirm correct understanding of the rules on self-isolation https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection and tick to confirm you are happy and understand the guidance.
    If you are in the shielding group, you may have received a letter from the government. Please refer to the following guidance for up to date information https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 and/or tick to confirm you are happy and aware of the advice
  • This field is for validation purposes and should be left unchanged.

Update your Details

Order your Prescriptions

Online Appointment Booking

Patient Participation Group

Download Practice Leaflet

Friends and Family Test

Print Blood Forms

Add Clinical Data BP/Smoking/Weight etc

Opening Times

  • Monday
    08:00am to 06:30pm
    Extended hours appointments (pre-booked only) 18:30-19:00
  • Tuesday
    08:00am to 06:30pm
    Extended hours appointments (pre-booked only) 18:30-19:00
  • Wednesday
    08:00am to 06:30pm
    Extended hours appointments (pre-booked only) 18:30-19:00
  • Thursday
    08:00am to 06:30pm
    Extended hours appointments (pre-booked only) 18:30-19:00
  • Friday
    08:00am to 06:30pm
    Extended hours appointments (pre-booked only) 18:30-19:00
  • Saturday
    CLOSED
  • Sunday
    CLOSED

Useful Links

NHS Choices
NHS 111
Patient UK
When I should Worry About My Child?
NHS A-Z Conditions
Find Local Services
Live Well
SurgeryWeb

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