COPD review

Section

Have you received a letter, text message or verbal invitation to complete this assessment? *

Yes

No

For each inhaler please tell us how many times each day you use the inhaler and how many puffs of the inhaler you use?

Name/colour of inhaler: *

How many times each day: *

How many puffs each time: *

Name/colour of inhaler:

How many times each day:

How many puffs each time:

Name/colour of inhaler:

How many times each day:

How many puffs each time:

Do you use a spacer when using your inhalers? *

Yes

No

Have you had any COPD exacerbations this year for which you have been prescribed steroid tablets (prednisolone) or antibiotics for your chest? *

Yes

No

How many prescriptions of oral steroids have you had in the past 12 months? *

How many prescriptions of antibiotics have you had in the past 12 months? *

Have you had any overnight hospital admissions relating to your lungs in the past 12 months? *

Yes

No

In which months were you admitted to hospital? *

Are you under the care of a hospital consultant? *

Yes

No

Do you cough up phlegm/sputum? *

Yes

No

Has this changed since your last review?

Yes

No

How often? *

Everyday

Most days

Few times a month

Can you describe the colour of the phlegm? *

Is this new for you in the past 12 months? *

Yes

No

Assessment

Coughing

Phlegm

Tightness

Stairs

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) *

Activities

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

Leaving

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) *

Sleep

Energy

Total Score

We would like to know about your level of breathlessness, please select the most appropriate comment: *

I only get breathless with strenuous exercise

I get breathless when hurrying on level ground or up a slight hill

I walk slower than people my age when walking on level ground because of breathlessness or have to stop to catch my breath when walking on level ground

I stop for breath after walking 100 yards or every few minutes

I am too breathless too leave the house most of the time

Has this changed since your last review? *

Yes

No

Are you able to exercise? *

Yes

No

Has this changed since your last review? *

Yes

No

What exercise do you do? *