COPD review

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Any responses we send will go to this email address.

Assessment

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)

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)

Total Score

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

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Assessment

Coughing

Phlegm

Tightness

Stairs

Activities

Leaving

Sleep

Energy

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