COPD and Breathlessness Review

If you have been advised by the surgery to submit a COPD and Breathlessness Review, please use this form.

This service is only available for currently registered patients – please register by completing our online New Patient Registration form if you are not already a patient with us.

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.

All messages will receive an email response (to the input address) – please check your email address given and junk/spam folder if you do not receive a response.

COPD and Breathlessness Review

Section

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

Breathlessness

Please select from one of the following options regarding your current level of breathlessness: *

Exacerbations

Smoking

Smoking status: *