Annual COPD assessment

Section

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

Assessment

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

Additional Questions

Do you have annual influenza vaccinations?

Yes

No

Have you ever had a pneumonia vaccine?

Yes

No

In the last year, how many times have you had an exacerbation (worsening of symptoms) where you have attended A&E or requested a rescue pack?

Do you use an inhaler?

Yes

No

Inhalers

Please specify your inhaler:

Does your inhaler contain steroids?

Yes

No

Do you rinse your mouth or clean your teeth after using the inhaler?

Yes

No

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

When are you available to take a call in the next few weeks?

Text/Email Consent

The practice can send you a text message or email with your appointment time and appointment reminder. *

I agree to the practice sending me text messages and emails including appointment times and appointment reminders

I do not agree to the practice sending me text messages and emails including appointment times and appointment reminders

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Please select one of the options below:

Consent: *

Express consent for medication, allergies and adverse reactions only.

Express consent for medication, allergies, adverse reactions and additional information – further medical information includes your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

Express dissent for Summary Care Record (opt out) – you do not want any information shared with other healthcare professionals involved in your care.

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

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