For patients who are due an annual asthma review.
Please would you answer the questions on the form below and submit it to us.
If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a doctor as well.
If you are not, did you know there is an online demonstration on the Asthma UK website or pop in and see our practice respiratory nurse for more advice.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Kensington Road Surgery
148 Kensington Road, Earlsdon, Coventry , CV5 6HY.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.