COPD review

Section

You have been invited by the surgery to complete this form to help the staff review your COPD. Please complete the following, allowing up to 4 weeks for your review to be completed.

Assessment

Coughing

Phlegm

Tightness

Stairs

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

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

Leaving

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) *

Sleep

Energy

Smoking Status:

Never Smoked

Ex Smoker

Current Smoker

If there is anything else you need to share with us regarding your COPD please do so below:

One of our clinicians will review the results of your assessment to determine if any intervention is required. If intervention is required staff will be in touch regarding arranging a follow-up appointment.

In order to complete your review, please choose one of the following two options: *

I have concerns and wish to discuss these in a follow-up appointment

I am happy to complete my review now without further discussion if appropriate

Please tell us when you are available to have an appointment in the next 3 weeks: *

Confirmation *

I understand that the practice may need to send me a secure online message about my appointment. I will check my emails.

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