Health Respiratory History

If you have been advised by the surgery to submit your health respiratory history, please use this form.

Health Respiratory History

Health Respiratory History

Patient Details

Please use date format DD/MM/YYYY

Respiratory History

Did you have any inhalers or respiratory problems as a child, such as asthma or bronchitis? *
Does anyone in your family have asthma or any other respiratory condition such as COPD or bronchiectasis? *
Does anyone in your family have hayfever / eczema / allergies? *
Do you have or have ever had hayfever / eczema / allergies? *
Have you ever been diagnosed with whooping cough or pneumonia either as a child or adult? *
Do you suffer with recurrent chest infections needing antibiotics or steroids (prednisolone) to treat it? *
Have you ever worked with dust, chemicals, or asbestos for any length of time or has your partner/wife/husband? *
Do you suffer with indigestion/heartburn? *
Smoking Status: *
Have you ever kept birds? *
Do you feel short of breath? *
Do you have chest tightness or wheeze? *
Do you have a cough? *
Is your cough: *
Are your respiratory symptoms worse in the mornings/evenings or at night particularly? (Please select all that apply)