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

Section

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

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

Do you use a spacer when using your inhalers? *
Have you had any COPD exacerbations this year for which you have been prescribed steroid tablets (prednisolone) or antibiotics for your chest? *
Have you had any overnight hospital admissions relating to your lungs in the past 12 months? *
Are you under the care of a hospital consultant? *
Do you cough up phlegm/sputum? *
Has this changed since your last review?
How often?
Is this new for you in the past 12 months?

Assessment

Coughing

I never cough
I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all
My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless
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
I am very limited doing any activities at home

Leaving

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

Sleep

I sleep soundly
I don't sleep soundly because of my lung condition

Energy

I have lots of energy
I have no energy at all

We would like to know about your level of breathlessness, please select the most appropriate comment: *
Has this changed since your last review? *

Are you able to exercise? *
Has this changed since your last review?
Has this changed since your last review?

Has your appetite changed in the past 12 months? *
Do you feel this is related to your COPD?
Has this changed since your last review?

Blood Pressure (if possible)

Smoking

Do you currently smoke? *
How many cigarettes do you smoke in a day? *
Would you like to give up smoking? *
Have you smoked in the past? *
How many cigarettes did you smoke in a day? *

Additional Information

Inhaler Technique

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): *
E.g. Monday AM/PM, Tuesday AM/PM