X

COPD Assessment

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 well-being 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.

Full Name:


Date of Birth:


Phone Number:


Email Address:


Assessment

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

0 - I have no phlegm (mucus) in my chest at all
1
2
3
4
5 - My chest is full of phlegm (mucus)

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

0 - When I walk up a hill or one flight of stairs I am not breathless
1
2
3
4
5 - When I walk up a hill or one flight of stairs I am very breathless

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

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

0 - I sleep soundly
1
2
3
4
5 - I don't sleep soundly because of my lung condition

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

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.