Asthma and COPD Review

If you have been advised by the surgery to submit an asthma and COPD review, please use this form. If your symptoms are deteriorating or you are having any concerns, please make an appointment with our Nurse.

Part of this assessment will help us measure the impact that 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.

Please be aware that any replies from the surgery may appear in your junk or spam inbox.

Asthma and COPD Review
Are you completing this form on behalf of: *

Please use this date format: DD/MM/YYYY. Your date of birth is required to verify your identity.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.
Confirmation *
Smoking Status:
Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what's right for you. For more information visit the Smokefree website.

Smoker

Would you like help to give up smoking?

Ex smoker

Do you vape?
For applicable devices
Do you require a translator?

Assessment

Have you had a respiratory illness in the last six weeks? *

COPD 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

How would you rate your degree of breathlessness related to activities: *