Annual COPD and asthma review

Your Information

Full Name: *

Phone Number:

Have you received a letter advising you to complete this review?

Yes

No

Please specify requester and date of letter:

Please use date format DD/MM/YYYY.

Patient Status

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Height:

Weight:

Alcohol Consumption:

Units per week

Do you smoke?

Yes

No

How many do you smoke in a day?

Would you like to be referred to a smoking cessation adviser?

Yes

No

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Are you an ex smoker?

Yes

No

What date did you give up smoking?

Please use date format DD/MM/YYYY.

How many did you smoke in a day?

Activity levels:

Does not regularly exercise

Enjoys moderate exercise

Exercises regularly

COPD

Coughing

Phlegm

Tightness

Stairs

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) *

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

Leaving

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) *

Sleep

Energy

Breathlessness

Please rate your level of breathlessness: *

I am not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after 100 yards or after a few minutes of walking on level ground

I am too breathless to leave the house and get breathless when getting dressed

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