COPD Questionnaire

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 Questionnaire

COPD Questionnaire

If you are human, leave this field blank.

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

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

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?

Has this changed since your last review?

Yes

No

What limits your exercise?

What is your current (or previous if retired) occupation? *

Has your appetite changed in the past 12 months? *

Yes

No

Do you feel this is related to your COPD?

Yes

No

Has this changed since your last review?

Yes

No

Blood Pressure (if possible)

Systolic "Higher"

Diastolic "Lower"

Heart Rate

Smoking

Do you currently smoke? *

Yes

No

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many years have you smoked for? *

Would you like to give up smoking? *

Yes

No

Have you smoked in the past? *

Yes

No

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many years did you smoke for? *

Additional Information

Height:

Weight:

Oxygen Saturations (if possible):

Inhaler Technique

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

Relvar Ellipta

Spiriva Respimat

Seebri Neohaler

Anoro Ellipta

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

If we need to contact you to discuss anything related to your form, when is the best time to contact you? *

E.g. Monday AM/PM, Tuesday AM/PM

Submit