COPD review

Section

Please select the best description of your cough from the list below:

Please select the best description of your symptoms at night:

No cough

Cough

Cough and wheeze

Difficulty breathing (breathlessness/shortness of breath)

Please select the best description of your breathing at night:

No breathlessness (normal breathing)

Breathlessness when lying flat

Severe breathlessness that wakes you up

Please select any symptoms of swelling (oedema) that apply to you:

Please select the answer that best describes your breathing:

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a slight hill

I walk slower than contemporaries (peers) on level ground due to breathlessness or stop if walking at my own pace

I stop for breath after walking 100 yards or after a few minutes on level ground

I am breathless when dressing or too breathless to leave the house

How many COPD exacerbations (attacks) have you had in the past year?

How many hospital admissions have you had due to your COPD in the past year?

Inhaler Technique

It 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 videos below to check that you are using your inhalers correctly:

COPD Foundation Inhaler Videos

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

Yes

No

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 alcohol

How often do you have a drink containing alcohol?

How often have you had 6 or more units (female) or 8 or more units (male) on a single occasion in the last year?

Lifestyle – Smoking

Do you smoke?

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40+ cigarettes per day)

Do you use an e-cigarette?

Never

Ex-user

Yes

If you smoke, would you like help to quit smoking?

Yes

No

For further information, please visit NHS Smokefree.

COPD Assessment Test

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled.

Please select a score of 0 to 5 to help assess the severity of your symptoms.

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless)

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home)

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition)

Total Score

This is automatically calculated and will be sent to the practice upon submission.

I have the following questions that I would like to raise with my COPD Nurse or Doctor:

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

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