New asthma patient

Referred with: []

History:
Symptoms: [wheeze, breathlessness, chest tightness, cough]
Duration and pattern: []
Diurnal variation and night waking: [nights per week]
Triggers: [exercise, cold air, pollen, animals, dust, aspirin or NSAIDs, work]
Better away from work or on holiday: [yes, no or not applicable]
Atopy: [eczema, hay fever, food allergy]
Nasal symptoms and sense of smell: []

Attack history:
Courses of oral steroids in the last 12 months: []
Attendances at A and E in the last 12 months: []
Hospital admissions, ever, and any HDU or ITU care: []
Best ever peak flow, and when: []

Current treatment and how it is actually taken:
Preventer: [drug, device, dose, doses per day]
Reliever: [drug, and doses used per week]
Inhaler technique observed today: [adequate or the specific error seen]
Adherence, by prescription collection where available: [collections in last 12 months]
Spacer in use: [yes or no]

Other:
Smoking and vaping: []
Occupation and exposures: []
Reflux, nasal polyps, obesity, anxiety or depression: []
Beta blockers, aspirin or NSAIDs: []
Height [] cm   Weight [] kg   BMI []

Objective tests:
Blood eosinophils [] x10^9/L
FeNO [] ppb
Spirometry FEV1 [] L ([]%), FVC [] L ([]%), ratio []%
Bronchodilator reversibility: [change in FEV1 in ml and %]
Peak flow diary: [amplitude per cent mean over two weeks]
Total IgE and specific IgE or skin prick: []
Chest x-ray: []

Impression:
[asthma confirmed on which test, or diagnosis not yet established]

Plan:
1. []
2. Inhaler technique checked and spacer issued: []
3. Written personalised asthma action plan given: [yes]
4. Trigger and adherence discussion: []
5. Review in [] weeks with [test or diary]