COPD Review

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COPD Review

* Indicates required field

Name *

DOB (dd/mm/yy) *

Contact number *

Which of the following best describes your breathing? *

I only get breathless on strenuous exercise I get short of breath when hurrying on a level or when walking up a slight hill I walk slower than most people the same age on level ground or have to stop for breath when walking at my own pace after 15 minutes I get short of breath after walking 100 yards or after a few minutes on level ground I’m too breathless to leave the house, or breathless when dressing / undressing

How many exacerbations of COPD have you had in the last 12 months? (an exacerbation is where your symptoms got worse and you needed to seek medical attention) *

Smoking status *

Current smoker Ex smoker Never smoked

how many cigarettes /day? *

if applicable

When did you stop? *

if applicable

For the questions below, you will need to provide a response that best describes your situation on a scale of 0-5.

Cough *

0 - I never cough 1 2 3 4 5 - I cough all the time

Mucus *

0 - I have no mucus on my chest at all 1 2 3 4 5 - My chest is full of mucus

Chest tightness *

0 - My chest does not feel tight at all 1 2 3 4 5- My chest feels very tight

Walking uphill *

0 - When I walk up a hill or flight of stairs I do not feel breathless at all 1 2 3 4 5 - When I walk up a hill or flight of stairs I feel completely out of breath

Activites *

0 - I am not limited doing any activities at home 1 2 3 4 5 - I am completely limited doing all activities at home

Leaving home *

0 - I am confident leaving home despite my lung condition 1 2 3 4 5 - I am not confident leaving my house at all because of my lung condition

Sleep *

0 - I sleep soundly 1 2 3 4 5 - I do not sleep soundly because of my lung condition

Energy *

0 - I have lots of energy 1 2 3 4 5 - I have no energy at all

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