COPD Questionnaire

COPD questionnaire

Please complete this form to update us on your current COPD symptoms

Name
MM slash DD slash YYYY
Please pick a statement which best sums up your level of activity and breathlessness by ticking the appropriate box below
If you score 2 or more, you may be eligible for pulmonary rehab (Lung Education & Exercise Programme – LEEP). This is a course run from Cossham hospital by the specialist respiratory team. They cover managing breathlessness, understanding your lung condition and can be as effective as starting a new medication. Please select if you would like to be referred.
Do you currently smoke?
Do you have asthma? Or have you been told that you have asthma in the last year?
Do you produce sputum?
Do you usually have the flu jab?
Have you had a Pneumonia jab?
On a scale of 0-5 with 0 being I never cough and 5 being I cough all of the time. Please select where you feel you currently are
On a scale of 0-5 with 0 being I have no phlegm (mucus) in my chest at all and 5 being my chest is completely full of phlegm (mucus). Please select where you feel you currently are
On a scale of 0-5 with 0 being my chest does not feel tight at all and 5 being my chest feels very tight. Please select where you feel you currently are
On a scale of 0-5 with 0 being when I walk up a hill or one flight of stairs I am not breathless and 5 being when I walk up a hill or one flight of stairs I am very breathless. Please select where you feel you currently are
On a scale of 0-5 with 0 being I am not limited doing any activites at home and 5 being I am very limited doing activities at home. Please select where you feel you currently are
On a scale of 0-5 with 0 being I am I am confident leaving my home despite my lung condition and 5 being I am not confident leaving my home because of my lung condition. Please select where you feel you currently are
On a scale of 0-5 with 0 being I sleep soundly and 5 being I don't sleep soundly because of my lung condition. Please select where you feel you currently are
On a scale of 0-5 with 0 being I have lots of energy and 5 being I have no energy at all. Please select where you feel you currently are

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