COPD Review

If you have been advised by the surgery to submit a COPD review 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.

Please ensure you check your Spam/Junk email folder for any replies. An appointment/reply will be sent back to you via an email.

Please visit the following link for patient Self-management apps to support people living with Asthma or COPD:

• www.healthhub.wales

COPD Review

COPD Review

If you are human, leave this field blank.

Have you been asked by the practice to complete this online review form? *

Yes

No

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

Height *

In Metres

Weight *

In Kg

BMI

Please note: BMI calculator is only for patients aged 18 and over.

Do you smoke?

Current smoker

Ex-smoker

Never smoked

Would you like to arrange an appointment for smoking cessation?

Yes

No

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

Total Score

This is automatically calculated and will be sent to the practice upon submission.

How would you describe your exercise tolerance?

1. Not troubled by exercise except on strenuous exercise

2. Short of breath when hurrying or walking up a slight hill

3. Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

4. Stops for breath after walking about 100m or after a few minutes on level ground

5. Too breathless to leave the house or breathlessness when dressing or undressing

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?

Yes

No

Since your last review, have you needed a course of steroid tablets to get your COPD under control?

Yes

No

Since your last review, have you had an exacerbation of your COPD?

Yes

No

In the last month have you have difficulty sleeping because of your COPD symptoms?

Yes

No

In the last month have you have your usual COPD symptoms during the day (cough, wheeze, chest tightness, or breathlessness?)

Yes

No

In the last month has your COPD interfered with your usual activities (Eg. housework, work/school, etc.)

Yes

No

Please select the types of inhalers 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

Did you have a flu vaccination last flu season?

Yes

No

Have you had your pneumonia vaccination?

Yes

No

Please add any further comments here:

Please tick box to consent to receive a SMS response from the nurse (if required).

Submit