COPD Annual Review

COPD Assessment

Section

What is your smoking status? *
Would you like information to help you quit? *

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

Score Under 10

A score under 10 may indicate that your COPD is having a low impact on your life. You may not require any urgent care treatment and may be able to continue with routine reviews. Please highlight any concerns at the end of the questionnaire.

Score between 10-20

A score between 10-20 may indicate that your COPD is having a medium impact on your life and there is room for improvement. The clinician who reviews this form may be in contact and arrange a follow up review with an advanced clinical practitioner.

Score in between 20-30

A score between 20-30 may indicate that your COPD is having a high impact on your life and there is significant room for improvement. The clinician who reviews this form will be in contact and arrange a follow up review with an advanced clinical practitioner.

Score over 30

A score over 30 may indicate that your COPD has a very high impact on your life and there is a significant room for improvement. The clinician who reviews this form will be in contact.

MRC Breathlessness Grade

Please rate your level of breathlessness: *

You may be eligible to be referred to pulmonary rehabilitation. Pulmonary Rehabilitation is an exercise and education programme designed for people with lung disease who experience symptoms of breathlessness. These are normally delivered in group sessions at a local venue.

Would you like a referral to pulmonary rehabilitation? *

Additional Questions

Do you have a cough? *
How would you describe your cough? *

Medication

Please select the types of inhalers that you use:
Do you use a spacer? *

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): *

Signs of a chest infection

If you are experiencing any of these symptoms, please contact the surgery or take your rescue pack if you have one.

  • increased breathlessness
  • Temperature and feeling unwell
  • New or increased wheeze and/or chest tightness
  • Increased quantity in sputum
  • New or worsening cough with yellow or green sputum
  • Feeling you need your reliever inhaler more often
  • Reduced daily activity and walking distance
*