COPD Review

Please complete the following questions to allow your health care professional to assess your COPD. This questionnaire is for a routine review of your COPD symptoms. 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.

Please select the practice location most relevant to this Online Form submission:

COPD Review

Name

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Address

1. Please select the best description of your cough from the list below:

No cough

Dry cough

Productive cough – Clear sputum

Productive cough – Green sputum

Productive cough – Yellow sputum

Sputum appearance – Frothy / Watery

Unable to cough up the sputum

2. Please select the best description of your symptoms at night:

No cough

Cough

Cough and Wheeze

Difficulty breathing (breathlessness / shortness of breath)

3. Please select the best description of your breathing at night:

No breathlessness (normal breathing)

Breathlessness when lying flat

Severe breathlessness that wakes you up

4. Please select any symptoms of swelling (oedema) that apply to you:

No swelling

Swelling of feet only

Swelling up to ankles

Swelling up to legs

Swelling up to thighs

5. Please select the answer that best describes your breathing:

I am short of breath on strenuous exercise

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

I walk slower than others on level ground due to breathlessness or stop if walking at my own pace

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

I am breathlessness or am to breathless to leave the house

6. How many COPD exacerbations (attacks) have you had in the past year?

How many hospital admissions have you had due to your COPD in the past year?

Inhaler Technique

It is essential to have a 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: For further information,

COPD Foundation Videos - https://www.copdfoundation.org/Learn-More/For-Patients-Caregivers/Educational-Video-Series/Inhaler-Training-Videos.aspx

I have watched the above relevant inhaler technique videos and am happy with my inhaler technique

Yes

Your Lifestyle- Alcohol

How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never

Less than Monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking?

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Yes, but not in the last year

Yes, during the last year

Your Lifestyle- Smoking

Do you smoke?

Never smoked

Ex-smoker

Yes

Do you use an e-cigarette?

Ex-user

Yes

How many cigarettes did/do you smoke a day?

Less than one

1-9

10-19

20-39

40+

Would you like help to quit smoking?

Yes

Further Questions

I have the following information, questions or concerns that I would like to raise with my COPD Nurse or Doctor:

Please see the following links for further information on COPD that you may find useful:

NHS Choices - http://www.nhs.uk/conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx

Patient. Info - http://patient.info/health/chronic-obstructive-pulmonary-disease-leaflet

British Lung Foundation - https://www.blf.org.uk/support-for-you/copd

COPD Assessment Test Score

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled. Please select a score of 0 to 5 to help assess the severity of your symptoms.

1. Cough:

0=I never cough

5 = I cough all the time

2. Phlegm / Mucous:

0=I have no phlegm (mucus) in my chest at all

5 = My chest is completely full of phlegm (mucus)

3. Chest Tightness:

0 = My chest does not feel tight

5 = My chest feels very tight

4. Breathlessness:

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

5 = When I walk up a hill or one flight of stairs I am very breathless

5. Activities:

0 = I am not limited at all doing any activities at home

5 = I am very limited doing activities at home

6. Confidence:

0 = I am confident leaving my house despite my lung condition

5 = I am not confident leaving my house because of my lungs

7. Sleep:

0 = I sleep soundly

5 = I don’t sleep soundly because of my lung condition

8. Energy:

0 = I have lots of energy

5 = I have no energy at all

Follow-Up

When you are happy with all your above answers, please return this questionnaire to your GP practice.

Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

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