Asthma Control Test (ACT)

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Name (to be completed by person requesting certificate)*

Date of Birth*

Contact Telephone Number (including mobile number if available)*

Email*

Is this a new request for a Med 3 or an extension?*

New

Extension

How long do you expect your illness to last?*

7 days or less

more than 7 days

If you expect to be ill for 7 days or less, your GP will NOT issue a free sick note. But you can still self certify your illness by completing the statement of sickness form on the HMRC website.

Have you seen a GP during this illness?*

Yes

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?*

Date from which certification is required:*

Date expected to return to work?*

Any other relevant information?

Consent*

I agree to the privacy policy

Signature*

Phone
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Name*
First Last
Date of Birth*
DD dash MM dash YYYY
Address
Street Address Address Line 2 City County / State / Region Postcode Country
Email*
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Telephone Number (including mobile number if available*
Name of medication required*
Please copy the name from the original packaging
Dosage*
How much of the medication do you take at a time?
Regularity*
How often do you take the medication?
Prescriber*
Who prescribed the medication, and when?
Reason*
Reason for taking this medication
Date on which medication was last prescribed*
DD slash MM slash YYYY
Date on which your medication runs out*
Additional Information*
Please provide any additional information which will help the Pharmacist, GP or Prescribing Nurse with your request.
Consent*
I agree to the privacy policy.
Signature*

Keith Health Centre

Asthma Control Test (ACT)

Asthma Control Test Score for People 12 years and Older

Opening Times

Useful Links

NHS A-Z Conditions

Live Well

Calculate your Heart Age

Check your Blood Pressure Reading

Keith Health Centre

Asthma Control Test (ACT)

Asthma Control Test Score for People 12 years and Older

Opening Times

Useful Links

NHS A-Z Conditions

Live Well

Calculate your Heart Age

Check your Blood Pressure Reading

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