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 wellbeing 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.

COPD Assessment (NEW)

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.

Phone Number:

Please let us know your preferred contact number in case we need to contact you.

NHS Number: (if known)

Email Address: *

This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

COPD Review

Please select the best description of your cough: *

No Cough

Dry Cough

Productive Cough - Clear Sputum

Productive Cough - Green Sputum

Productive Cough - Yellow Sputum

Sputum Appearance - Frothy/Watery

Unable to Cough up Sputum

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

Sever breathlessness that wakes you up

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

No swelling

Swelling of feet only

Swelling up to ankles

Swelling up to legs

Swelling up to thighs

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 am too breathless to leave the house

How many COPD exacerbations (attacks) have you had 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:

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Lifestyle - Alcohol

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times a month

2-3 times a week

4 times or more a week

How many units of alcohol do you drink on a typical day drinking? Please see: www.drinkaware.co.uk *

1-2

3-4

5-6

7-9

10+

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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 or more cigarettes per day)

Do you use an e-cigarette?

No

Ex-user

Yes

Would you like help to quit smoking?

Yes

No

For further information, please see: www.nhs.uk/smokefree

Further Questions

I have the following information, questions or concerns 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:

• www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/
• NHS COPD
• Patient.Info
• British Lung Foundation

COPD Assessment Test Score

Coughing

I never cough

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all

Phlegm: from 0 (I have no phlegm - mucus - in my chest at all) to 5 (My chest is full of phlegm - mucus) *

0

1

2

3

4

5

My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless

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) *

0

1

2

3

4

5

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

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

0

1

2

3

4

5

I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition

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) *

0

1

2

3

4

5

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

Sleep

I sleep soundly

Sleep: from 0 (I sleep soundly) to 5 (I don't sleep soundly because of my lung condition) *

0

1

2

3

4

5

I don't sleep soundly because of my lung condition

Energy

I have lots of energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

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