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Asthma review (adults)

Asthma Review

About You

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Do you smoke?

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Is this form being completed for someone under the age of 19?
Has the child been exposed to second hand smoke?
e.g. 1.75
e.g. 60.6
BMI calculator is only for patients aged 18 and over. The BMI will not calculate without a valid height and weight.
Would like to be referred for help with weight loss?