COPD Review

If you have been advised by the surgery to submit a COPD review please use this form.

This assessment will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your score will be used by us to help improve the management of your COPD and get the greatest benefit from treatment.

COPD Review

COPD Review

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
In Metres
In Kg
Please note: BMI calculator is only for patients aged 18 and over.
Do you smoke?
Would you like to arrange an appointment for smoking cessation?

Assessment

Coughing

I never cough
I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all
My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless
When I walk up a hill or one flight of stairs I am very breathless

Activities

I am not limited doing any activities at home
I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly
I don't sleep soundly because of my lung condition

Energy

I have lots of energy
I have no energy at all
Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your COPD?
Since your last review, have you needed a course of steroid tablets to get your COPD under control?
Since your last review, have you had an exacerbation of your COPD?
In the last month have you have difficulty sleeping because of your COPD symptoms?
In the last month have you have your usual COPD symptoms during the day (cough, wheeze, chest tightness, or breathlessness?)
In the last month has your COPD interfered with your usual activities (Eg. housework, work/school, etc.)
Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *
Did you have a flu vaccination last flu season?
Have you had your pneumonia vaccination?