COPD Questionnaire | Cherryvalley Group Practice

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Kings Square, Kings Road, Belfast BT5 7BP

Tel: 028 9040 1844

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COPD

COPD Questionnaire

Please fill out the following form to help us assess how well controlled your COPD is.

First Name

Last Name

Date of Birth

Please tell us your smoking status *

Never smoked

Ex smoker

Current smoker

Relating to the number of exacerbations within the last year (when your COPD flared and you required antibiotics and/or steroids) *

I have had no exacerbations within the last year

I have only had one exacerbation within the last year

I have either been admitted to hospital with my COPD over the last year OR I have had 2 or more exacerbations within the last year

I cannot recall whether I have had any exacerbations within the last year

Which number would you assign relating to cough? *

0 - I never cough

5 - I cough all the time

Which number would you assign relating to phlegm/ mucus? *

0 - I have no phlegm/ mucus in my chest at all

5 - My chest is completely full of phlegm/ mucus

Which number would you assign relating to chest tightness? *

0 - My chest does not feel tight at all

5 - My chest feels very tight

Which number would you assign relating to walking up a hill or flight of stairs? *

0 - When I walk up a hill or one flight of stairs I am not breathless

5 - When I walk up a hill or one flight of stairs I am very breathless.

Which number would you assign relating to ability to do activity at home? *

0 - I am not limited doing any activities at home

5 - I am very limited doing activities at home

Which number would you assign relating to confidence in leaving home due to lung condition? *

0- I am confident leaving home despite my lung condition

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

Which number would you assign relating to sleep? *

0- I sleep soundly

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

Which number would you assign relating to energy levels? *

0 - I have lots of energy

5 - I have no energy at all

Today's date

Thanks for submitting!

Kings Square, Kings Road, Belfast BT5 7BP, Northern Ireland

Tel: 0280 9040 1844

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