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Stow Surgery NHS GP Surgery in Stow on the Wold

COPD review

COPD Assessment (New)

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Please select the best description of your cough from the list below: *

No cough

Dry cough

Productive cough, clear sputum

Productive cough, green sputum

Productive cough, yellow sputum

Sputum appearance, frothy/watery

Unable to cough up the sputum

Please select any symptoms of swelling (oedema) that apply to you: *

No swelling

Swelling of feet only

Swelling up to ankles

Swelling up to legs

Swelling up to thighs

Please select the best description of your symptoms at night: *

No cough

Cough

Cough and wheeze

Difficulty breathing (breathlessness/shortness of breath)

Please select the best description of your breathing at night: *

No breathlessness (normal breathing)

Breathlessness when lying flat

Severe breathlessness that wakes you up

Please select the answer that best describes your breathing: *

Short of breath on strenuous exercise

Short of breath when hurrying or walking up a slight hill

Breathlessness or am to breathless to leave the house

Please answer the following using a scale of 0 – 5, 0 being the least.

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

0

1

2

3

4

5

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

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) *

0

1

2

3

4

5

Activities

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

0

1

2

3

4

5

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) *

0

1

2

3

4

5

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

How many COPD exacerbation’s (attacks) have you had in the past year? *

Inhaler Technique

Please select the types of inhalers that you use: *

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

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

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

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Your Lifestyle – Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

If you are human, leave this field blank.

Sending

Maugersbury Road
Stow on the Wold
Gloucestershire
GL54 1AX

Get directions

01451 830625

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