TALK TO YOUR DOCTOR

Ready to start a conversation about asthma?

If asthma symptoms are standing in the way of your everyday life, it’s time to work with your doctor to set a plan of action.

Answer the following questions, and use them as a guide when talking to your doctor about uncontrolled asthma.

The answers to this questionnaire are not intended to diagnose a condition or disease state. They should be used as a conversation starter when talking to your doctor about your treatment options for asthma. When you review this form with your doctor, have a list of your medications.

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1. Are you already taking medication for asthma?

2. Which of these symptoms do you experience? Choose all that apply.

3. In what ways do asthma symptoms affect your everyday life? Choose all that apply.

4. Have you ever had to seek urgent/emergency medical attention because of asthma?

5. Is there anything that is more difficult for you to do today than at your last visit because of asthma symptoms? Choose all that apply.

Email this form to yourself. This will include the answers you provided.

The email address you provide will only be used to send you this Doctor Discussion Guide form. GSK will not use the email address you provide in any other way. GSK will not sell or transfer your information to any other party for any reason.

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PAY AS LITTLE AS $0*

for up to 12 months

For eligible commercially insured patients, such as those insured through an employer.

*Maximum savings $2400/year. Restrictions apply.

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