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St James Medical Practice NHS GP Surgery in King’s Lynn, West Norfolk

COPD review

COPD Assessment

Section

Alcohol Consumption

Please visit www.drinkaware.co.uk/tools/unit-and-calorie-calculator

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times a month

2-3 times a week

4 times or more a week

How many units of alcohol do you drink on a typical day 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

Smoking

Do you smoke?

Yes

No

Please specify: *

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette?

Yes

Ex-user

No

Would you like help to quit smoking?

Yes

No

Please visit www.nhs.uk/smokefree for advice on qutting smoking.

Assessment

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

Total Score

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

Please specify: *

I am not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after 100 yards or after a few minutes of walking on level ground

I am too breathless to leave the house and get breathless when getting dressed

Have you taken any antibiotics/steroids in the last year?

Yes

No

Have you been admitted into hospital in the last year?

Yes

No

Further Questions

I have the following questions that I would like to raise with my COPD Nurse or Doctor:

Please visit the following links for further information on COPD that you may find useful:

NHS: Chronic Obstructive Pulmonary Disease
Patient Info: Chronic Obstructive Pulmonary Disease
British Lung Foundation: Support for your COPD

If you are human, leave this field blank.

Edward Benefer Way
South Wootton
Kings Lynn
Norfolk
PE30 2FQ

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01553 774 221

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