Rxpress

Salbutamol Supply Consultation Form

Date of Birth (DD/MM/YYYY):

Age:

Full Name:

Home Address:

Email:

Telephone:

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

Eligibility Questions for Salbutamol Replacement

1. Is this medicine for your own use?
YesNo

2. Have you been diagnosed with asthma by a healthcare professional?
YesNo

3. Have you used salbutamol (blue inhaler) before?
YesNo

4. Are you currently experiencing asthma symptoms (e.g. wheezing, breathlessness, chest tightness)?
YesNo

5. Are you experiencing severe symptoms such as extreme difficulty breathing or inability to speak full sentences?
YesNo

6. Do you currently have a salbutamol inhaler?
YesNo

7. How frequently do you use your salbutamol inhaler?
DailyWeeklyMonthlyRarely

8. Are you currently prescribed a preventer (steroid) inhaler (e.g. brown inhaler)?
YesNo

9. Are you taking any other medication (prescription or over-the-counter)?
YesNo

Please list any medications you are currently taking:

10. Have you ever had an allergic reaction to salbutamol or any component of the inhaler?
YesNo

11. Are you currently under emergency care for asthma or respiratory problems?
YesNo

Do we have permission to access your medical records?
YesNo