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COPD review

COPD Assessment

Please select the best description of your cough from the list below:
Please select the best description of your symptoms at night:
Please select the best description of your breathing at night:
Please select any symptoms of swelling (oedema) that apply to you:
Please select the answer that best describes your breathing:
Your answers indicate that you may benefit from pulmonary rehabilitation. Do you want to be referred to pulmonary rehabilitation if you meet the criteria?

Assessment

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled.

Please select a score of 0 to 5 to help assess the severity of your symptoms.

Coughing

Phlegm

Tightness

Breathlessness

Activities

Confidence

Sleep

Energy

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

Smoking status

Do you currently smoke?
How many cigarettes do you smoke per day?
Have you ever smoked?
How many cigarettes did you smoke per day before you quit?
Do you use an electronic cigarette (vape)?
Have you ever used an electronic cigarette (vape)?
Are you regularly exposed to second hand tobacco smoke?
Where are you exposed to second hand tobacco smoke?
Are you happy for your COPD review to be marked as complete?

What happens next?

Once you click submit below, this form will be submitted to the practice and passed onto our COPD team to review. Depending on your answers they will either:

  • Mark your COPD review as complete
  • Ask reception to contact you to arrange an appointment

To ensure that you have a full COPD review at least once a year, you will be asked to complete this every year during your birth month.