Enhanced COPD Assessment

If you have been advised by the surgery to submit a COPD assessment please use this form.

This assessment will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your score will be used by us to help improve the management of your COPD and get the greatest benefit from treatment.

Enhanced COPD Assessment

Enhanced COPD Assessment

If you are human, leave this field blank.

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

Do you smoke? Please select one... Never smoked tobacco Ex smoker Smoker Trivial cigarette smoker (less than 1 cigarette/day) Light cigarette smoker (1-9 per day) Moderate cigarette smoker (10-19 per day) Heavy cigarette smoker (20-39 per day) Very heavy cigarette smoker (40+per day) Exposed to tobacco smoker in public places Exposed to tobacco smoke at work Exposed to tobacco smoke at home User of electronic cigarette Ex user of electronic cigarette

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:

Gets no exercise

Enjoys light exercise

Enjoys moderate exercise

Enjoys heavy exercise

Exercise physically impossible

Diet

Please select one:

Diet average

Diet good

Diet poor

Food intolerance diet

Renal diet

Vegetarian diet

Vegan diet

Weight reducing diet

Weight gain 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

I never cough

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

0

1

2

3

4

5

I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all

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

My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all

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

0

1

2

3

4

5

My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless

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

When I walk up a hill or one flight of stairs I am very breathless

Activities

I am not limited doing any activities at home

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

I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition

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

I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly

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

0

1

2

3

4

5

I don't sleep soundly because of my lung condition

Energy

I have lots of energy

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

0

1

2

3

4

5

I have no energy at all

Alcohol

This is one unit of alcohol:

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

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

View your score