COPD Assessment Extended
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Smoking Status

What is your current smoking status?

Risk Exposures

Do you have any risk exposures?

Inhalers

Please select the types of inhaler that you use:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s)

Home Nebuliser and Oxygen

Are you currently using a home nebuliser?
Are you currently undergoing oxygen therapy?

Hospital Admissions

Have you attended A&E since your last annual review?
Please use format DD/MM/YYYY
Have you had an emergency COPD admission since your last appointment?
Please use formate DD/MM/YYYY

Keep Active and Well

Please specify unit of measurement eg. CM, Feet and Inches
Please specify unit of measurement eg. lbs, KG
What is your exercise level?
How would you rate your diet?

Assessment

Coughing

Phlegm

Tightness

Stairs

Activities

Leaving

Sleep

Energy

Score

If your score is less than 10:

Breathlessness on Target – Well Done

Your COPD appears to have been under control over the last 4 weeks. However, if you are experiencing symptoms your doctor or nurse may be able to help you, please add these int the comments box at the end of this form.

If you score between 11 and 20

On Target

Your COPD appears to have been reasonably well controlled during the past 4 weeks. However, if you are experiencing symptoms your doctor or Nurse may be able to help you, please let a doctor or nurse know.

21 to 30

Monitoring Needed

Your COPD appears that it may not be under control during the past 4 weeks.
Your Doctor or nurse may recommend a COPD action plan to help improve your COPD control once you have submitted this form.

If your score is more than 30:

Off Target

Your COPD may not have been controlled during the past 4 weeks.
Your Doctor or nurse will recommend a COPD action plan to help improve your COPD control once you have submitted this form.

Additional Questions

You may be offered Pulmonary Rehabilitation as a result of your COPD assessment, are you happy for this referral to take place?
If you are completing this form survey between September-December, are you happy to receive a flu vaccination, if eligible?
If you are aged 70 or 78 when completing this form, would you like to receive a shingles vaccination?

Yours answers will now be reviewed by a member of the Hollies Medical Practice team; if there are any concerns over your answers or information missed we will contact you with an appointment.