COPD Review Form

If you have chronic obstructive pulmonary disease (COPD) please use this form to aid in your annual review.

Last Updated: 21/02/2023

Your Details

Name *

Date of Birth *

Contact Number *

Email Address *

I consent to the Practice communicating via SMS Text Messaging and Email *

Yes

Breathlessness Review

HOW DO YOU RATE YOUR LEVEL OF BREATHLESSNESS? *

0 - I’m not troubled by breathlessness at all even on strenous exercise

1 - I only get breathless when I undertake vigorous exercise

2 - I get short of breath when hurrying on a level or walking up a slight hill

3 - I walk slower than most people on the level but can walk for a mile or so

4 - I have to stop for breath after a few minutes of walking a short distance on level ground

5 - I’m too breathless to leave the house and get breathless when getting dressed

Thinking about your cough use the scale below to score yourself *

0 - I never cough

5 - I cough all the time

Thinking about phlegm (mucus) on your chest use the scale below to score yourself *

0 - I have no phlegm on my chest at all

5 - My chest is full of phlegm

Thinking about chest tightness use the scale below to score yourself *

0 - My chest does not feel tight at all

5 - My chest feels very tight

Thinking about your exercise ability use the scale below to score yourself *

0 - When I walk up a hill or a flight of stairs I am not out of breath

5 - When I walk up a hill or a flight of stairs I am completely out of breath

Thinking about limits to activities use the scale below to score yourself *

0 - I am not limited to doing any activities at home

5 - I am completely limited to doing all activities at home

Thinking about leaving the house use the scale below to score yourself *

0 - I am confident leaving my home despite my lung condition

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

Thinking about your sleeping use the scale below to score yourself *

0 - I sleep soundly

5 - I do not sleep soundly because of my lung condition

Thinking about your energy levels use the scale below to score yourself *

0 - I have lots of energy

5 - I have no energy at all

Inhaler use, smoking and pulmonary rehabilitation

How often to you need to use your ventolin (blue) inhaler? *

Rarely such as when undertaking strenous excertion/unwell

2-3 times a week

Once or twice a day

Every couple of hours

Are you taking your COPD inhalers every day? *

Yes No

Do you have any problems with your COPD inhaler? *

Yes No

Would you like a referral for pulmonary rehabilitation, an exercise program with education and support to help you breath and function to the best of your ability? *

Yes No

Do you smoke? *

Never

Stopped within the last year

Stopped >1yr ago

1-10 per day

11-20 per day

21-30 per day

+30 per day

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form

Oops... There was an error contacting reCAPTCHA, Please try again.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

COPD Review Form

Further Information