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 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

COPD Assessment

Section

Assessment

How often do you cough?

I never cough
I cough all the time

How much phlegm do you feel you have on your chest?

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

How tight is your chest?

My chest does not feel tight at all
My chest feels very tight

When do you get out of breath?

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

How much are you limited by your COPD when at home?

I am not limited doing any activities at home
I am very limited doing any activities at home

How confident do you feel leaving your home with your lung condition?

I am confident leaving my home despite my lung condition
I am not at all confident leaving my home despite my lung condition

How well do you sleep?

I sleep soundly
I don't sleep soundly because of my lung condition

How much energy do you have?

I have lots of energy
I have no energy at all

How out of breath do you get?

*

COPD Exacerbations

An exacerbation is where your breathlessness or cough got worse and you needed to take a rescue pack or seek medical attention (see www.blf.org.uk - Managing COPD Flare-Ups for more information)

An exacerbation is where your breathlessness or cough got worse and you needed to take a rescue pack or seek medical attention (see www.blf.org.uk - Managing COPD Flare-Ups for more information)

Smoking Status

What is your smoking status? *
How much do you smoke? *

Smoking leads to health problems such as cancer, heart disease, and strokes. The benefits of stopping smoking include: better health, more money, and cleaner air for those around you!

Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: www.nhs.uk/smokefree.