COPD review

Section

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time)

Phlegm

Tightness

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless)

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home)

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition)

Sleep

Energy

Total Score

This is automatically calculated and will be sent to the practice upon submission.

Additional Questions

Do you smoke?

Yes

Ex smoker

Never smoked

How many do you smoke per day?

Would you like to stop smoking?

Yes

No

Would you like us to contact you about stopping?

Yes

No

Are you happy with your inhaler technique?

Yes

No

Would you be interested in Pulmonary Rehab?

Yes

No

Please state the number of exacerbations you’ve had in the last year?

Breathlessness Review

Please rate your level of breathlessness:

I am not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after 100 yards or after a few minutes of walking on level ground

I am too breathless to leave the house and get breathless when getting dressed

*

I confirm that the information provided is accurate to the best of my knowledge

Tell us whether you accept cookies