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Asthma

- tell us about your condition

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Intro

Medical

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What is your gender

Do you believe that you have the capacity to make decisions about your own healthcare?

Yes

No

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

Yes

No

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

No

Please provide more detail.

Do you suffer from any allergies?

Yes

No

Please provide details including which allergies and what symptoms you experience.

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

Yes

No

Please provide more detail.

Do you understand that this service is not suitable for treating emergency asthma or COPD symptoms?

If you are struggling with your breathing, having an asthma attack or have any chest pains or discomfort call 999 and go to A+E

Confirm

Are you aware that the following symptoms require urgent medical treatment:

Your lips or fingers turning blue (cyanosis).
You need to use your reliever inhaler more than every four hours.
Wheezing, coughing and chest tightness becoming severe and constant.
Being too breathless to eat, speak or sleep.
Breathing faster.
Your reliever inhaler (which is usually blue) is not helping symptoms as much as usual, or at all.
A rapid heartbeat.
Feeling drowsy, exhausted or dizzy.

Confirm

Do you suffer from Asthma or COPD?

Has your Asthma or COPD been diagnosed by a doctor?

Yes

No

Please explain why you are requesting this treatment

How long have you suffered from Asthma/COPD?

When was the last time you had an asthma/COPD review at your GP surgery?

Please provide the month and the year.

Are you currently using a reliever inhaler? (blue inhaler/ventolin/salbutamol/bricanyl)

Yes

No

Which reliever inhaler are you using?

Why are you not using a reliever inhaler?

Are you currently using a preventer inhaler? (e.g brown inhaler/clenil/fostair/seretide)

Yes

No

Which preventer inhaler are you using?

Why are you not using a preventer inhaler?

Have you been given inhalers within the last 2 months?

Including those prescribed by your GP, hospital, online or any other healthcare service provider.

Yes

No

Why are you requesting inhalers today?

Including those prescribed by your GP, hospital, online or any other healthcare service provider.

Over the past month, how many times have you been short of breath?

Over the past month, did your asthma/COPD affect you being able to achieve what you wanted to?

This can be in work, outside of work or at home.

Over the past month, how many times did your asthma/COPD symptoms get you up at night?

Over the past month, please tell us how controlled your asthma/COPD has been?

Have you been to the hospital because of your condition in the last 12 months?

Yes

No

Please provide details

Are you aware that you should attend a review for your condition with your GP/Nurse every 12 months?

I confirm that I understand and agree to the above

Are you confident with the use of the inhaler you have requested today?

Yes

No

Are you currently registered with a GP Practice?

Yes

No

Would you like us to notify your GP of the treatment you chose to order today?

Yes

No

GP Practice Name, GP Postcode, GP Telephone Number

GP Information

Please provide your GP surgery details.

Consent & Declarations

I confirm that my answers are true and accurate and that I have read and agree to the Terms and Conditions and Privacy Policy.

Its required to fill all details.

Do you agree to the following:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

Yes

No

Please complete all required questions.

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We're rated excellent!

Your online consultation is reviewed by qualified prescribers before treatment is approved.

Trusted UK service

Standards of Service

GPhC regulated pharmacy, encrypted forms, and secure handling of your personal and medical data.

Need help?

Send an email to [email protected] if you need support before completing this consultation.

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