Annual COPD and Asthma Review

If you have been advised by the surgery to submit an annual asthma and COPD review, please use this form. If your symptoms are deteriorating or you are having any concerns, please make an appointment with our Nurse.

Part of this assessment will help us measure the impact that 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.

Annual COPD and Asthma Review

Your Information

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Have you received a letter advising you to complete this review?
Please use date format DD/MM/YYYY.

Patient Status

/
Units per week
Do you smoke?
Would you like to be referred to a smoking cessation adviser?
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?
Please use date format DD/MM/YYYY.
Activity levels:

COPD

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

Breathlessness

Please rate your level of breathlessness: *