COPD Assessment

Please complete the following questions to allow your health care professional to assess your COPD. This questionnaire is for a routine review of your COPD symptoms. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

COPD Assessment (New)
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
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: *

Inhaler Technique

Please select the types of inhalers that you use: *

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): *

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