New COPD Review Form

This form is used for your annual COPD review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

COPD Review

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your COPD?

Yes No

Since your last review, have you needed a course of steroid tablets to get your COPD under control?

Yes No

Do you smoke?

Yes No

Did you have a flu vaccination last flu season?

Yes No

Please list the inhalers you use daily or on a regular basis (name/strength/how many puffs/how many times a day/via a space device?)

COPD Assessment Test (CAT)

This questionnaire will help you and your healthcare professional measure the impact COPD is having on your wellbeing and daily life. Your answers, and test score can be used by you and your healthcare professional to help improve the management of your COPD and get the greatest benefit from treatment.

For each item below tick in the box that best describes you currently, be sure to only select one response for each question

Example: i am very happy 0 1 2 3 4 5 I am very sad

Modified MRC Dyspnea Scale

Please tick in the box that applies to you | ONE BOX ONLY | Grades 0-4 *

MRC Grade0. i only get breathless with strenuous exercise

MRC Grade 1. I get short of breath when hurrying on level ground or walking up a slight hill

MRC Grade 2. On level ground, I walk slower than people of my age because of breathlessness, or I have to stop for breath when walking at my own pace on the level

MRC Grade 3. I stop for breath after walking about 100 yards or after a few minutes on level ground

MRC Grade 4. I am too breathless to leave the house or I am breathless when dressing/undressing

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

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New COPD Review Form

New COPD Review Form

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