COPD review form

 

Please fill in as much information as you can about the current state of your COPD. Once submitted the information will be entered into your clinical record and reviewed by a Practice Nurse , usually within five working days. If there are no issues they will arrange for your medications to be reauthorised by your usual GP, otherwise they will give you a call to discuss your COPD over the phone.

    Personal Details

    Your Name:
    Your Date of Birth:
    Contact Tel Number:
    Your Email Address:

    COPD Symptoms and Treatment

    1. Please choose a score for each of the following symptoms of your COPD depending on its severity as per the statements at each end.
    I never cough 012345 I cough all the time
    I have no phlegm (mucus) in my chest at all 012345 My chest is full of phlegm (mucus)
    My chest does not feel tight at all 012345 My chest feels very tight
    When I walk up a hill or one flight of stairs I am not breathless 012345 When I walk up a hill or one flight of stairs I am very breathless
    I am not limited doing any activities at home 012345 I am very limited doing activities at home
    I am confident leaving my home despite my lung condition 012345 I am not at all confident leaving my home because of my lung condition
    I sleep soundly 012345 I don't sleep soundly because of my lung condition
    I have lots of energy 012345 I have no energy at all
    2. Can you please choose your level of breathlessness from the following scale?
    3. How many chest infections requiring antibiotics, or hospital admissions related to your lung condition, have you had in the last year?
    4. Do you have rescue medications at home for a chest infection? YesNo

    Lifestyle

    What is your current smoking status?
    If you are a current smoker, how much do you smoke a day?

    Self-Management Plan

    Do you have an NHS Lothian COPD Self-Management Plan? YesNoDon't know
    If yes, do you understand and are you happy with the information it contains? YesNoDon't know

    Other Information

    Is there any other information you would like to let us know or discuss about your COPD?

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