COPD Questionnaire

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.

COPD Questionnaire

Section

Have you received a letter, text message or verbal invitation to complete this assessment?

For each inhaler please tell us how many times each day you use the inhaler and how many puffs of the inhaler you use?

Do you use a spacer when using your inhalers? *
Have you had any COPD exacerbations this year for which you have been prescribed steroid tablets (prednisolone) or antibiotics for your chest? *
Have you had any overnight hospital admissions relating to your lungs in the past 12 months? *
Do you cough up phlegm/sputum? *
Has this changed since your last review?
How often?
Is this new for you in the past 12 months?

We would like to know about your level of breathlessness, please select the most appropriate comment: *
Has this changed since your last review? *

Are you able to exercise? *
Has this changed since your last review?

Has your appetite changed in the past 12 months? *
Do you feel this is related to your COPD?
Has this changed since your last review?

Blood Pressure (if possible)

Smoking

Do you currently smoke? *
Have you smoked in the past? *
How many cigarettes did you smoke in a day? *
How many cigarettes do you smoke in a day? *
Would you like to give up smoking? *

Additional Information

E.g. Monday AM/PM, Tuesday AM/PM