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.

COPD Assessment

COPD Assessment

Section

Alcohol Consumption

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day 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?

Smoking

Do you smoke?
Please specify: *
Do you use an e-cigarette?
Would you like help to quit smoking?

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

Assessment

Coughing

I never cough
I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all
My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless
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
I am very limited doing any activities at home

Leaving

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

Sleep

I sleep soundly
I don't sleep soundly because of my lung condition

Energy

I have lots of energy
I have no energy at all
Have you taken any antibiotics/steroids in the last year?
Have you been admitted into hospital in the last year?

Further Questions

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