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.

COPD Assessment

COPD Assessment

Section

How out of breath do you get? *

Assessment

Coughing

I never cough
I cough all the time

Phlegm

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

Tightness

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

Stairs

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

Activities

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

Leaving

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

Sleep

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

Energy

I have lots of energy
I have no energy at all
Did you go into hospital because of any COPD exacerbations?
Do you smoke?

We strongly advise you to quit smoking. You can get advice on ways to quit smoking and general tips from: www.smokefreenorfolk.nhs.uk or please call 0800 085 4113.

Pulmonary rehabilitation is a treatment programme that can help you stay active if you have a lung condition. It consists of physical exercises and advice from professionals about managing your condition. Have you already completed pulmonary rehab?
Would you like to be referred for pulmonary rehabilitation?

Further information on Pulmonary Rehabilitation can be found below: