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COPD review

COPD Review
Have you been asked by the practice to complete this online review form? *
Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

Section

In Metres
In Kg
Please note: BMI calculator is only for patients aged 18 and over.
Do you smoke?
Would you like to arrange an appointment for smoking cessation?

Assessment

Coughing

Phlegm

Tightness

Stairs

Activities

Leaving

Sleep

Energy

This is automatically calculated and will be sent to the practice upon submission.
How would you describe your exercise tolerance?
Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your COPD?
Since your last review, have you needed a course of steroid tablets to get your COPD under control?
Since your last review, have you had an exacerbation of your COPD?
In the last month have you have difficulty sleeping because of your COPD symptoms?
In the last month have you have your usual COPD symptoms during the day (cough, wheeze, chest tightness, or breathlessness?)
In the last month has your COPD interfered with your usual activities (Eg. housework, work/school, etc.)
Please select the types of inhalers 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): *
Did you have a flu vaccination last flu season?
Have you had your pneumonia vaccination?