COPD Review

If you have been advised by the surgery to submit a COPD review, please use this form.

This review 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 Review

COPD Review

Section

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

Additional Questions

Please tick which statement best applies to your level of breathlessness:
Have you had to take rescue antibiotics or steroids in the last year?

Please ensure you are recording the date of any exacerbations and that you arrange for a GP or nurse review within 2 days of the start of the event.

If you have a rescue pack of antibiotics and/or steroids, have you checked that they are in date?
Please select the types of inhalers that you use:

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

Ellipta

Please watch this short video on how to use your Ellipta inhaler: How to use a Ellipta inahler

Respimat

Please watch this short video on how to use your Respimat inhaler: How to use a Respimat inhaler

Genuair

Please watch this short video on how to use your Genuair inhaler: How to use a Genuair inhaler

Zonda

Please watch this short video on how to use your Zonda inhaler: How to use a Zonda inhaler

HandiHaler

Please watch this short video on how to use your HandiHaler inhaler: How to use a HandiHaler inhaler

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

If you are having any problems with your inhaler technique, please call the surgery to speak to Angela or Julie.

If you have a spacer/chamber to use with your inhaler please ensure you have had a new one in the last 6-12 months.

Smoking Status:

It has been found to be beneficial for patients with COPD to undertake Pulmonary Rehabilitation programmes. You may already have done so. It consists of education about the disease and assistance with exercise. Currently Pulmonary rehabilitation is not being run as a face to face programme but is still being offered with over the internet or by phone.

Please tick which applies: