This Doctor Discussion Guide will help you talk to your doctor about asthma. Just fill in the blanks, then print this page and bring it to your doctor's visit.

I have asthma, or think I might.

I have been diagnosed with asthma.
I have not been diagnosed with asthma, but I think that I might have it.

I'd like to talk about my asthma symptoms (check all that apply):

wheezing
coughing
shortness of breath
chest tightness
difficulty breathing
chest pain

My asthma triggers are (check all that apply):

I don't know food additives (e.g., sulfites)
mould viral infections
pollen physical activity
animal dander stress
cockroaches gastroesophageal reflux disease (GERD)
dust mites medications (e.g., beta-blockers, ASA (Aspirin®) and other nonsteroidal anti-inflammatory drugs (NSAIDs))
smoking other:
secondhand smoke other:
strong odours, such as paint fumes other:
cold air other:
air pollution other:
humidity other:

Treatments (check all that apply):

Medications I'm using it I'd like
to learn
more
Combination medications
Controller plus reliever
budesonide - formoterol (Symbicort®) How long:
Controllers
fluticasone – salmeterol (Advair®) How long:
Relievers
ipratropium - fenoterol (Duovent®) How long:
Relievers
Fast-acting bronchodilators: beta agonists
formoterol (Oxeze® and Foradil®) How long:
salbutamol (Ventolin® and generics) How long:
terbutaline (Bricanyl®) How long:
orciprenaline (generics) How long:
Controllers
Long-lasting bronchodilators: beta agonists
formoterol (Foradil®, Oxeze®) How long:
salmeterol (Serevent®) How long:
Long-lasting bronchodilators: theophylline products
aminophylline (Phyllocontin®, generics) How long:
oxtriphylline (Choledyl®, generics) How long:
theophylline (Theolair®, Uniphyl®, generics) How long:
Corticosteroids: inhaled
beclomethasone (Qvar®) How long:
budesonide (Pulmicort®) How long:
ciclesonide (Alvesco®) How long:
fluticasone (Flovent®) How long:
Corticosteroids: oral
cortisone (generics) How long:
dexamethasone (generics) How long:
hydrocortisone (Cortef®) How long:
prednisolone (generics) How long:
prednisone (generics) How long:
Leukotriene antagonists
montelukast (Singulair®) How long:
zafirlukast (Accolate®) How long:
Other controllers
sodium cromoglycate (Intal Inhaler®) How long:
ketotifen (Zaditen®) How long:
omalizumab (Xolair®) How long:
Other strategies to manage asthma I'm using it I'd like
to learn
more
Avoiding asthma triggers How long:
Asthma action plan How long:

I'm concerned about my asthma control.

I don't know whether my asthma is well controlled.
I'm concerned my asthma may not be well controlled (Take the Asthma Control Challenge)

I also have some other concerns:

I'm not sure what my asthma medications are for.
I'm not sure how or when to use my asthma medication.
I'm concerned about side effects.
I'm concerned that my treatment may interact with other medications I'm taking.
Other:______________________________________________________
Other:______________________________________________________

If a new treatment is recommended, I have some questions:

Is this a controller, a reliever, or both?
How do I use this treatment?
How much will this treatment help my symptoms?
When can I expect it to start working?
What can I do if I'm not sure whether my treatment is working?
What side effects should I expect?
Are there any changes I should make to my lifestyle?
 
Other questions:
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