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FOR CLINICIAN USE ONLY

DO YOU THINK YOUR PATIENT HAS ASTHMA?

DO THEY HAVE A WHEEZE, SHORTNESS OF BREATH, CHEST
TIGHTNESS OR COUGH?
If they are:
  • Between 5 and 69 years old.
  • Have no other lung disease that you know of.
  • Either be a non-smoker OR an ex-emoker(≤10 pack year history) OR current smoker (≤10 pack year history).
  • Not pregnant.
  • Have not taken oral corticosteroids for 4 weeks, inhaled corticosteroids for 2 weeks and antibiotics for 2 weeks prior to their first appointment. Therefore patients on regular inhaled steroids are not suitable for RADicA.
  •  
    Please download and give the patient a copy of the Patient Infomation Leaflet
    R1 Click here to download the
    *Patient Information Leaflet*
    R1
    PLEASE FILL IN THIS FORM AND CLICK SUBMIT
    Any queries ring: 07790911507 / 0161 291 3553
    Patient Name
    Date of Birth
    NHS Number
    Patient Contact Number(s)
    Patient Contact Email
    Referring Clinician Name
    Referring Clinician Contact Number
    GP Practice
    GP Contact Number
      Submit
     
    No patient information will be stored on this website
    National Institute for Health Research (NIHR) Clinical Research Center building
    Wythenshawe Hospital
    Southmoor Road
    M23 9LT