COPD Review

Step 1 of 6

16%

Who are you submitting this request for?

What is your relationship to the patient? OptionalPlease answer this section if you are completing the form on behalf of someone else.

About you (The patient)

Name

First Last

Date of Birth

DD slash MM slash YYYY

Mobile

Address

Street Address Address Line 2 City County / State / Region Postcode Country

What is you sex assigned at birth?

Female

Male

Based on your current situation, please rate the severity of your cough on a scale of 0-5

0 - I have no cough

5 - I cough all the time

Based on your current situation, please rate the severity of your phlegm (mucus) on a scale of 0-5

0 - I have no phlegm (mucus) on my chest at all

5 - My chest is full of phlegm (mucus)

Based on your current situation, please rate the severity of your chest tightness on a scale of 0-5

0 - My chest does not feel tight at all

5 - My chest feels very tight

Based on your current situation, please rate the severity of your breathlessness on a scale of 0-5

0 - When I walk up a hill or a flight of stairs I am not out of breath

5 - When I walk up a hill or a flight of stairs I am completely out of breath

Based on your current situation, please rate how limited to doing activites at home you are on a scale of 0-5

0 - I am not limited to doing any activities at home

5 - I am completely limited to doing all activities at home

Based on your current situation, please rate how confident you are leaving your home despite your lung condition on a scale of 0-5

0 - I am confident leaving at home despite my lung condition

5 - I am not confident leaving my home at all because of my lung condition

Based on your current situation, please rate how soundly you sleep on a scale of 0-5

0 - I sleep soundly

5 - I do not sleep soundly because of my lung condition

Based on your current situation, please rate your energy levels on a scale of 0-5

0 - I have lots of energy

5 - I have no energy at all

Which one of these best describes your breathing?

0 - I only get short of breath on strenuous exercise

1 - I get short of breath when hurrying or walking up a slight hill

2 - I have to stop for breath when walking at my own pace

3 - I have to stop for breath after a few minutes of walking on level ground

4 - I am too breathless to leave the house, or i get short of breath when getting dressed

Would you like a referral for pulmonary rehabilitation?Pulmonary rehabilitation is a program of exercise, education and support to help you breathe and function to the best of your ability:

Yes

I don't know

Have you had any exacerbations (flare-ups) of your COPD in the last 12 months?A flare-up is a worsening of your breathing, cough or sputum (mucus) that may require antibiotics, steroids, or both.

Yes

How many exacerbations (flare-ups) of your COPD have you had in the last 12 months?If you answered no, please enter 0

Have you been admitted to hospital for urgent treatment of your COPD in the last 12 months?

Yes

How many of your exacerbations in the last 12 months have required treatment with steroid tablets?

Have you ever been admitted to an intensive care unit (ICU) because of your COPD?

Yes

Please tell us when you were admitted to ICU and what happened. OptionalPlease answer this section if you answered yes for the above question.

Do you use inhalers for your breathing?

Yes

Which inhalers do you use for your breathing? OptionalPlease answer this section if you answered yes for the above question.

Do you use a spacer device with your inhaler?A 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.

Yes, all of the time

Yes, some of the time

Do you have a nebuliser at home?A nebuliser delivers a large dose of your inhaler treatment straight into your lungs.

Yes

Do you have oxygen at home (either long-term oxygen therapy or oxygen using a mask)?

Yes

Do you have steroid tablets at home in case your condition worsens suddenly?

Yes

Do you have antibiotic medication at home in case your condition worsens suddenly?

Yes

Please provide you height.Please indicate whether it is cm or feet.

Please provide you weightPlease indicate whether it is kg or stones.

Do you consume alcohol?

Yes

On average, how many units of alcohol do you drink each week?1 pint of beer is approximately two units and one small glass of wine is 1 unit.

Do you smoke?

No, I have never smoked

No, but I used to smoke

Yes - 1 to 9 cigarettes a day

Yes - 10 to 19 cigarettes a day

Yes - 20 to 39 cigarettes a day

Yes - 40 cigarettes a day or more

I smoke other things: vapes, cigars etc.

Do you have any allergies?For example, medications, creams or food.

Yes

Please tell us what you are allergic to. OptionalPlease state below if you answered yes to the question above.

Are you, or is there a chance you might be, pregnant?

Yes

Are you breastfeeding?

Yes

Is there anything else you would like to inform the GP / Clinician about you COPD condition? OptionalPlease 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.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff.

We have a strict confidentiality policy.

This information is not shared with any third party organisations.

I agree to the privacy policy.

Cookies on this website

ImportantImportant

COPD Review

COPD Review

About you (The patient)

Additional Information