LOCATIONS
Bradgate
Avonmouth
Ridingleaze
Northern Arc PCN
SELF CARE
Self Care - Adults
Self Care for Children
Carers
Drugs & Alcohol
Dental Problems
Domestic Violence
Ear Wax
Exercise On Referral
Frailty
Hayfever
Health costs
Insomnia (sleep)
Mental Health
Stop Smoking
Work, Benefits and Finances
FAQs
## TopTenTips ##
Group A Streptococcus
AccuRx
Blood Tests
Book An Appointment
Fees for non-NHS work
LGBT+
New Patients
Online Access (NHS App)
Referrals
Register with us
Repeat Medication
Saturday Morning Surgery
Sicknotes
Suspected Cancer
Test results
Video Consultations
When we're closed
SERVICES
Immunisations (Vaccines)
Cervical Screening / Smear
Flu Vaccines
Health & Wellbeing Coaching
4YP
Pregnancy
Physio
Repeat Dispensing
Research
Safeguarding / child protection
Sexual health contraception
Social Prescribing Adults
Social Prescribing Kids
Stop Smoking
Travel Clinic
DVLA / Private Medicals
CONDITIONS
Asthma / COPD
Bereavement
Cardiovascular Disease
Chronic Pain
Coronavirus Support
Dementia
Diabetes
Pre-diabetes
High Blood Pressure
Learning Difficulties
Mental Health
Sick Day Rules
STAFF
Doctors
Nurse Practitioners
Practice Nurses
Healthcare Assistants
Urgent Care Team
Management Team
Reception & Admin
COMMUNITY
Patient Participation Group
Breast Feeding
Transgender Patients
Community Toilet Scheme
Green Impact
ParkRun
Refugees
Resus Training
RSVP Volunteer Drivers
Newsletter
CONTACT
Feedback / Concerns
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
Submit
LOCATIONS
Bradgate
Avonmouth
Ridingleaze
Northern Arc PCN
SELF CARE
Self Care - Adults
Self Care for Children
Carers
Drugs & Alcohol
Dental Problems
Domestic Violence
Ear Wax
Exercise On Referral
Frailty
Hayfever
Health costs
Insomnia (sleep)
Mental Health
Stop Smoking
Work, Benefits and Finances
FAQs
## TopTenTips ##
Group A Streptococcus
AccuRx
Blood Tests
Book An Appointment
Fees for non-NHS work
LGBT+
New Patients
Online Access (NHS App)
Referrals
Register with us
Repeat Medication
Saturday Morning Surgery
Sicknotes
Suspected Cancer
Test results
Video Consultations
When we're closed
SERVICES
Immunisations (Vaccines)
Cervical Screening / Smear
Flu Vaccines
Health & Wellbeing Coaching
4YP
Pregnancy
Physio
Repeat Dispensing
Research
Safeguarding / child protection
Sexual health contraception
Social Prescribing Adults
Social Prescribing Kids
Stop Smoking
Travel Clinic
DVLA / Private Medicals
CONDITIONS
Asthma / COPD
Bereavement
Cardiovascular Disease
Chronic Pain
Coronavirus Support
Dementia
Diabetes
Pre-diabetes
High Blood Pressure
Learning Difficulties
Mental Health
Sick Day Rules
STAFF
Doctors
Nurse Practitioners
Practice Nurses
Healthcare Assistants
Urgent Care Team
Management Team
Reception & Admin
COMMUNITY
Patient Participation Group
Breast Feeding
Transgender Patients
Community Toilet Scheme
Green Impact
ParkRun
Refugees
Resus Training
RSVP Volunteer Drivers
Newsletter
CONTACT
Feedback / Concerns