COPD Review

COPD Review

Please note that you will be asked to provide your height and weight.

Please answer this section if you are completing the form on behalf of someone else.

About you (The patient)

Name  Required
Date of Birth  Required
Address  Required
What is you sex assigned at birth?  Required

About Your COPD

Based on your current situation, please rate the severity of your cough on a scale of 0-5  Required
Based on your current situation, please rate the severity of your phlegm (mucus) on a scale of 0-5  Required
Based on your current situation, please rate the severity of your chest tightness on a scale of 0-5  Required
Based on your current situation, please rate the severity of your breathlessness on a scale of 0-5  Required
Based on your current situation, please rate how limited to doing activites at home you are on a scale of 0-5  Required
Based on your current situation, please rate how confident you are leaving your home despite your lung condition on a scale of 0-5  Required
Based on your current situation, please rate how soundly you sleep on a scale of 0-5  Required
Based on your current situation, please rate your energy levels on a scale of 0-5  Required
Which one of these best describes your breathing?  Required
Would you like a referral for pulmonary rehabilitation?  RequiredPulmonary rehabilitation is a program of exercise, education and support to help you breathe and function to the best of your ability:
Have you had any exacerbations (flare-ups) of your COPD in the last 12 months?  RequiredA flare-up is a worsening of your breathing, cough or sputum (mucus) that may require antibiotics, steroids, or both.
If you answered no, please enter 0
Have you been admitted to hospital for urgent treatment of your COPD in the last 12 months?  Required
Have you ever been admitted to an intensive care unit (ICU) because of your COPD?  Required
Please answer this section if you answered yes for the above question.
Do you use inhalers for your breathing?  Required
Please answer this section if you answered yes for the above question.
Do you use a spacer device with your inhaler?  RequiredA spacer is a large, empty plastic device (or tube) that helps you get the right amount of medicine from your inhaler straight to your lungs.
Do you have a nebuliser at home?  RequiredA nebuliser delivers a large dose of your inhaler treatment straight into your lungs.
Do you have oxygen at home (either long-term oxygen therapy or oxygen using a mask)?  Required
Do you have steroid tablets at home in case your condition worsens suddenly?  Required
Do you have antibiotic medication at home in case your condition worsens suddenly?  Required
Please indicate whether it is cm or feet.
Please indicate whether it is kg or stones.
Do you consume alcohol?  Required
1 pint of beer is approximately two units and one small glass of wine is 1 unit.
Do you smoke?  Required
Do you have any allergies?  RequiredFor example, medications, creams or food.
Please state below if you answered yes to the question above.
Are you, or is there a chance you might be, pregnant?  Required
Are you breastfeeding?  Required
Please be aware that this will not be reviewed by a GP or clinician immediately. Therefore, if your matter is urgent, please contact the surgery directly.
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