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COPD review

COPD Assessment
Required fields are labelled
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Assessment

Coughing

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

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus)

Tightness

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

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)

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home)

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)

Sleep

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

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all)
This is automatically calculated and will be sent to the practice upon submission.