Asthma Control Test (ACT)

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Asthma Control Test Score for People 12 years and Older

Contact Telephone Number:

Total Score*

If your score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your nurse/doctor to see if things can be improved.

URL

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Name (to be completed by person requesting certificate)*

Contact Telephone Number (including mobile number if available)*

Name of GP you have seen about this illness*

On what date did you last see a GP about this illness?*

What do you understand to be the diagnosis?*

What symptoms are you currently suffering from?*

Any other relevant information?

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This field is for validation purposes and should be left unchanged.

Asthma Control Test Score for People 12 years and Older

Contact Telephone Number:

Total Score*

If your score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your nurse/doctor to see if things can be improved.

Date of Birth(Required)

Contact telephone number(Required)

What type of HRT do you use? Please include the name and dose, if known(Required)

If you answered YES to the previous question, please tell us the type of coil and when you had it fitted

How long have you been taking HRT?(Required)

If you answered YES to the previous question, when did you have a hysterectomy?

If you answered YES to the previous question, please tell us which family member(s) have been affected by breast cancer.

If you answered YES to the previous question, how often do you get your headaches or migraines?

Please tell us your weight?

Please tell us your height?

Please provide a recent blood pressure reading (taken within the last month), with your systolic (upper, first) and diastolic (lower, second) values (for example: 120/80.

If you do not own a BP monitor, you can use one in the health centre without the need for an appointment. Ask at reception.

If you answered YES to the previous question, please tell us how many cigarettes you smoke daily?

If you answered YES to the previous question, please tell us what allergies you have:

Is there anything else you would like to tell us that we have not asked? (Please answer below)

Contact Details (as requested above)

PLEASE READ THE FOLLOWING INFORMATION AND TICK THE BOX BELOW TO ACKNOWLEDGE YOUR UNDERSTANDING:

Most women benefit from HRT in terms of health and quality of life. There are, however, some risks to HRT which should be considered.

HRT can carry a small increased risk of breast cancer. It is important to take your HRT correctly, as prescribed, to protect the womb lining from thickening, which can increase the risk of cancer of the womb. There is also an increased risk of blood clots depending on the type of HRT prescribed and individual risk factors. Health benefits and reduced risks can be gained by eating a healthy diet, regular exercise, not smoking, restricting alcohol consumption to recommended limits and maintaining a healthy weight where possible. It is also important to attend regularly for cervical smears and breast screening as indicated and to be breast aware and examine your breasts regularly and report any changes to your doctor.

If you would like to read more about the benefits and small risks of HRT, there are many websites offering advice:

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Keith Health Centre

Asthma Control Test (ACT)

Asthma Control Test Score for People 12 years and Older

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