COPD Assessment

If you have been advised by the surgery to submit a COPD assessment please use this form.

This assessment will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your score will be used by us to help improve the management of your COPD and get the greatest benefit from treatment.

COPD Assessment Extended

COPD Assessment Extended

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address:

Email Address: *

Any responses we send will go to this email address.

Smoking Status

What is your current smoking status?

Never smoked tobacco

Ex-Smoker

Light Smoker 1-9 per day

Moderate Smoker 10-19 per day

Heavy Smoker 20-39 per day

Risk Exposures

Do you have any risk exposures?

Exposure to polluted air

Construction/ mining worker

Exposure to toxic dust, occupational

Exposure to polluted air, occupational

Exposure to toxic agricultural agents, occupational

Occupational exposure to toxic agents

Exposure to occupational risk factors

Inhalers

Please select the types of inhaler that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

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) *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Home Nebuliser and Oxygen

Are you currently using a home nebuliser?

Yes

No

Other

Please specify:

Are you currently undergoing oxygen therapy?

Yes

No

Other

Please specify:

Hospital Admissions

Have you attended A&E since your last annual review?

Yes

No

Date:

Please use format DD/MM/YYYY

Have you had an emergency COPD admission since your last appointment?

Yes

No

Date:

Please use formate DD/MM/YYYY

Keep Active and Well

Height:

Please specify unit of measurement eg. CM, Feet and Inches

Weight

Please specify unit of measurement eg. lbs, KG

What is your exercise level?

Enjoys moderate exercise

Excessive exercise

Little levels of exercise

No exercise

Light levels of exercise

Moderate levels of exercise

How would you rate your diet?

Diet poor

Diet Good

Diet Average

My weight has increased

My weight has decreased

I am concerned about my levels of weight loss

I have intentionally lost weight

My weight has remained stable

Other

Please specify:

Assessment

Coughing

I never cough

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

I cough all the time

Phlegm

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

Phlegm: from 0 (I have no phlegm - mucus - in my chest at all) to 5 (My chest is full of phlegm - mucus) *

0

1

2

3

4

5

My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

My chest feels very tight

Stairs

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

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

0

1

2

3

4

5

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

Activities

I am not limited doing any activities at home

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

0

1

2

3

4

5

I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

0

1

2

3

4

5

I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly

Sleep: from 0 (I sleep soundly) to 5 (I don't sleep soundly because of my lung condition) *

0

1

2

3

4

5

I don't sleep soundly because of my lung condition

Energy

I have lots of energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

I have no energy at all

Score

Total 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?

Yes

No

If you are completing this form survey between September-December, are you happy to receive a flu vaccination, if eligible?

Yes

No

If you are aged 70 or 78 when completing this form, would you like to receive a shingles vaccination?

Yes

No

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.

*

I certify that I have answered these questions to the best of my knowledge and have not omitted information that may affect my future health

Submit