COPD

COPD Questionnaire

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

Please tell us your smoking status
Relating to the number of exacerbations within the last year (when your COPD flared and you required antibiotics and/or steroids)
Which number would you assign relating to cough?
Which number would you assign relating to phlegm/ mucus?
Which number would you assign relating to chest tightness?
Which number would you assign relating to walking up a hill or flight of stairs?
Which number would you assign relating to ability to do activity at home?
Which number would you assign relating to confidence in leaving home due to lung condition?
Which number would you assign relating to sleep?
Which number would you assign relating to energy levels?

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

Tel: 0280 9040 1844

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