COPD review

Section

Have you received a letter advising you to complete this review?

Yes

No

Please specify requester and date of letter:

Please use date format DD/MM/YYYY.

In the last year, how many times have you had an exacerbation (worsening of symptoms) where you have attended A&E or requested a rescue pack?

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

Total Score

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

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