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Orchard Medical Centre NHS GP Surgery in Kingswood, South Gloucestershire

COPD review

COPD Assessment

Section

I give my consent for SMS text messaging *

Yes

No

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

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

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

Stairs

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

Activities

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

Leaving

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

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

How out of breath do you get?

1 – Not troubled by breathlessness except on strenuous exercise

2 – short of breath when hurrying, or walking up a slight hill

3 – I walk slower than people the same age on level ground because of breathlessness, or I have to stop for breath when walking at my own pace

4 – I get short of breath after walking 100 yards or after a few minutes on level ground

5 – I am too breathless to leave the house or breathless when dressing or undressing

How many COPD exacerbations have you have had in the past 12 months?

What is your smoking status?

Current smoker

Ex-smoker

Never smoked

How many cigarettes do you smoke per day?

If you are human, leave this field blank.

Sending

Macdonald Walk
Kingswood
South Gloucestershire
BS15 8NJ

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0117 980 5100

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