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Grafton Square Surgery NHS GP Surgery in Grafton Square, London SW4

COPD review

COPD Assessment

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Please specify the ethnic group the patient belongs to: *

Please specify: *

Do you smoke?

Current Smoker

Ex Smoker

Never Smoked

When did you stop?

How many did you smoke per day?

How many cigarettes are smoked a day?

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

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) *