COPD Health Review

If you have been advised by the surgery to submit a COPD health review, please use this form.

This review will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life.

COPD Health Review

COPD Health Review

Section

Are you a smoker?
Would you like help to quit smoking?
Please select the one that best describes you:

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

Do you have a cough?
Is it any of the below? Tick all that apply:
Is your cough at any of the below? Tick all that apply:
Do you cough up phlegm or sputum?
Is it any of the below? Tick all that apply:
Do you get a wheeze at any of the below? Tick all that apply:
Do you have any swelling? Tick all the apply:
Are you ok with using your inhaler?
Do you use a spacer?
Do you have a supply of rescue/emergency medication for your copd?
Have you done or been offered pulmonary rehabilitation?
Would you like a referral if applicable?
Have you had a flu vaccine?
Have you had a pneumo vaccine?