COPD review

COPD annual review

Please only fill out this form if you have been asked to by the practice. This questionnaire is for routine annual review of your COPD. 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 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?

Smoking makes COPD worse. Please follow this link to get help to quit smoking

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.

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

COPD review

COPD annual review

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