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.

COPD Review
Please enter Date of Birth as DD/MM/YYYY
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

Your Lifestyle- Alcohol
Your Lifestyle- Smoking
Further Questions

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.

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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