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Woodcock Road Surgery NHS GP Surgery in Norwich

COPD review

COPD Assessment

Section

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

Total Score

This is automatically calculated and will be sent to the practice upon submission.

MRC Scale Breathlessness

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

Grade 1 – Not troubled by breathlessness except on strenuous exercise.

Grade 2 – Short of breath when hurrying or walking up a slight hill.

Grade 3 – Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace.

Grade 4 – Stops for breath after walking about 100m or after a few minutes on level ground.

Grade 5 – Too breathless to leave the house, or breathless when dressing or undressing.

I am happy to be referred for pulmonary rehabilitation

Additional Questions

Have you had antibiotics or steroids for your lungs in the past 12 months?

Yes

No

Have you been to hospital for your lung condition in the past 12 months?

Yes

No

Have you got a COPD action plan?

Yes

No

Do you currently smoke?

Yes

No

Would you like to be referred to the Smoking Cessation Clinic?

Yes

No

Do you use an inhaler? *

Yes

No

Inhalers

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

If you are human, leave this field blank.

29 Woodcock Road
Norwich
Norfolk
NR3 3UA

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01603 425989

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