Asthma and COPD Annual Review

Asthma and COPD review form

Please only fill out this form if you have been asked to by the practice. This questionnaire is for routine annual review of your Asthma/COPD symptoms. Please complete the form to the best of your ability and when you are happy with all your answers, click submit below and the questionnaire will be automatically sent to the practice. Depending on your answers, you will be contacted if you need to be seen in the practice for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Name

First Last

Date of birth

Address

COPD review - 1 - Please select the answer that best describes your breathing.

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a hill

I walk slower than contemporaries (peers) on level ground due to breathlessness or stop if walking at my own pace

I stop for breath when walking 100 yards or after a few minutes on level ground

I am breathless when dressing or am too breathless to leave the house

This question is for those with COPD

COPD review - 2 - How many COPD exacerbations (attacks) have you had in the past year? (please enter a number)

This question is for those with COPD

COPD review - 3 - How many hospital admissions have you had due to your COPD in the past year? (please enter a number)

Inhaler technique - I have watched the below relevant inhaler technique video in the weblink below and am happy with my inhaler technique

For everyone with COPD or asthma, it is essential to have good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly. COPD Foundation Videos https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Educational-Video-Series.aspx

Smoking

please select the option that best fits you

Do you use an e-cigarette or vape?

1 - COPD Assessment Test Score - cough

Please select the score of 0 - 5 to help assess the severity of your cough.

2 - COPD Assessment Test Score - Phlegm/Mucous

Please select the score of 0 - 5 to help assess the severity of your Phlegm/Mucous.

3 - COPD Assessment Test Score - Chest Tightness

Please select the score of 0 - 5 to help assess the severity of your symptoms.

4 - COPD Assessment Test Score - Breathlessness

Please select the score of 0 - 5 to help assess the severity of your breathlessness.

5 - COPD Assessment Test Score - Activities

Please select the score of 0 - 5 to help assess the severity of your symptoms.

6 - COPD Assessment Test Score - Confidence

Please select the score of 0 - 5 to help assess the severity of your symptoms.

7 - COPD Assessment Test Score - Sleep

Please select the score of 0 - 5 to help assess the impact on your sleep.

8 - COPD Assessment Test Score - Energy

Please select the score of 0 - 5 to help assess your energy levels.

COPD Assessment Test Score - TOTAL

Please calculate your overall COPD Assessment Test Score (out of 45) by adding up the 8 different components of the COPD Assessment test score.

1 - Asthma Control Test (these next steps are only for those 12 years and older) - this provides a score to help us determine if your asthma symptoms are well controlled.

In the past 4 weeks, how often did your asthma prevent you from getting as much done at work/school/home?

2 - Asthma Control Test

In the past 4 weeks, how often have you had shortness of breath?

3 - Asthma Control Test

In the past 4 weeks, how often did your asthma symptoms wake you up at night or early in the morning?

4 - Asthma Control Test

In the past 4 weeks, how often have you used your reliever inhaler (usually blue)?

5 - Asthma Control Test

How would you rate your asthma control?

Asthma Control Test Score TOTAL

Please calculate your total score out of 25 by adding up the 5 parts of the asthma control test.

Any questions/concerns (optional)

Use the box above to enter any issues that you would like to raise with our clinical pharmacist or GP.

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Drs Foster, Logan, and Macdonald

Asthma and COPD Annual Review

Asthma and COPD review form

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