Enhanced COPD review

Patient Details

Your First Names: *

Your Last Name: *

Your Date of Birth: *

Please use the format DD/MM/YYYY.

Your Phone Number: *

Your Email: *

Smoking

I would like smoking cessation advice

MRC Grade

Please specify: *

Short of breath only on strenuous exercise

Short of breath when hurrying or walking up a slight hill

Walks slower than contemporaries on level as breathless or stops if walking at own pace

Stops for breath after walking 100 yards on level ground or after a few minutes

Breathless if dressing or too breathless to leave the house

Exercise

Please select one:

Diet

Mental Health

Mood:

Normal mood

Depressed mood

Memory:

Memory function normal

Memory impairment

Anxiety:

Feeling calm

Feeling anxious

Assessment

Please visit the Dispensary to have your height, weight and blood pressure taken.

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.

Alcohol

This is 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? *

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