Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare?

Do you know how and when to use your inhaler?

Have you called an ambulance or had emergency treatment for breathing problems in the last year?

Do you use your inhaler more than four times a day?

Have you been diagnosed with asthma by your doctor or nurse?

Do you drink alcohol?

Do you smoke?

Do you suffer from asthma or COPD?

How long have you suffered from asthma/COPD?

Has your Asthma been reviewed by a doctor or nurse within the last 12 months?

Are you currently using a reliever inhaler? (Blue inhaler/Salbutamol/Ventolin/Bricanyl)

Are you currently using a preventer inhaler? (e.g. Brown inhaler/Clenil/Fostair/Seretide)

How often are you woken up at night by your condition?

How many days a week do you have symptoms (eg cough, wheeze, shortness of breath, chest tightness)?

Have you been to hospital because of your condition in the last 12 months?

Is your asthma well controlled?

If you are not sure take the asthma control test here.

Do you have an allergy (hypersensitivity) to Ventolin (salbutamol) or have you had a reaction with an asthma inhaler previously?

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Have you been diagnosed with any of the following?

• Overactive thyroid gland
• History of heart problems such as an irregular or fast heartbeat or angina
• High blood pressure
• Hypokalemia (low level of potassium)
• Any serious medical condition which may require immediate hospitalisation

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Do you understand that you must seek medical attention if your asthma does not improve within 1 hour of using your inhaler?

Are you aware that you should attend an annual review of your condition with your GP every 12 months?

Are you confident with the use of the inhaler you are requesting today?

Do you agree to the following?

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.