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

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Assessment

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 despite 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

Please select the best description of your cough from the list below: *

No cough

Dry cough

Productive cough - clear sputum

Productive cough - green sputum

Productive cough - yellow sputum

Sputum appearance - frothy/watery

Unable to cough up sputum

Please select the best description of your symptoms at night: *

No cough

Cough

Cough and wheeze

Difficulty breathing (breathlessness / short of breath)

Please select the best description of your breathing at night: *

No breathlessness (normal breathing)

Breathlessness when lying flat

Severe breathlessness that wakes you up

Please select any symptoms of swelling (oedema) that apply to you:

No swelling

Swelling of feet only

Swelling up to ankles

Swelling up to legs

Swelling up to thighs

Please select the answer that best describes your breathing: *

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a slight hill

I walk slower than peers on level ground due to breathlessness or stop if walking at my own pace

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

I am breathless when dressing or am too breathless to leave the house

How many COPD exacerbations (attacks) have you had in the past year? *

How many hospital admissions have you had due to your COPD in the past year? *