COPD Assessment

Please only complete the following questionnaire if requested by your GP practice as part of your COPD review.

This questionnaire is for a routine review of your COPD symptoms. If you are experiencing severe shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

COPD Assessment

COPD Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

COPD Review

Please select the best description of your cough from the list below:
Please select any symptoms of swelling (oedema) that apply to you:
Please select the best description of your breathing at night:
Please select the best description of your symptoms at night:
Please select the answer that bests describes your breathing:

Inhaler Technique

Is is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly: 

COPD Foundation Inhaler Videos

I have watched the above relevant inhaler technique videos and am happy with my inhaler technique:

Lifestyle - Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you think you drink on a typical day drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Lifestyle - Smoking

Do you smoke?
Do you use an e-cigarette?
If you smoke, would you like help to quit smoking?

For further information, please see: NHS Quit Smoking information page

Further Questions

Please see the following links for further information on COPD that you may find useful:

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

When you are happy with all your above answers, please select submit below and the questionnaire will be automatically sent to your GP practice. Depending on your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book and appointment if required.