COPD Assessment

If you have been advised by the surgery to submit a COPD assessment please use this form.

This assessment will help us measure the impact of 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.

Depending on your score, you may need to be referred for pulmonary rehabilitation. Pulmonary rehabilitation is a programme of exercise and education for people with a long-term lung condition. For more information, please visit the British Lung Foundation website or NHS England website.

COPD Assessment

COPD Assessment




I never cough
I cough all the time


I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)


My chest does not feel tight at all
My chest feels very tight


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


I am not limited doing any activities at home
I am very limited doing any activities at home


I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition


I sleep soundly
I don't sleep soundly because of my lung condition


I have lots of energy
I have no energy at all

MRC Scale Breathlessness

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

Additional Questions

Have you had antibiotics or steroids for your lungs in the past 12 months?
Have you been to hospital for your lung condition in the past 12 months?
Have you got a COPD action plan?
Do you currently smoke?
Would you like to be referred to the Smoking Cessation Clinic?
Do you use an inhaler? *


Please select the types of inhalers that you use:

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): *