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.
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.
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.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.