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.

Last Updated: 03/07/2023

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

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? (optional)

Yes

No

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

Yes

No

Do you smoke? (optional)

Yes

No

Did you have a flu vaccination last flu season? (optional)

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?) (optional)
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

I never cough 0 1 2 3 4 5 i cough all the time

0

1

2

3

4

5

I am confident leaving my home despite my lung condition 0 1 2 3 4 5 I am not at all confident leaving my home because of lung condition (optional)

1

2

3

4

5

i sleep soundly 0 1 2 3 4 5 I don't sleep soundly because of my lung condition (optional)

1

2

3

4

5

I have lots of energy 0 1 2 3 4 5 i have no energy at all (optional)

1

2

3

4

5

I have no phlegm (mucus) in my chest at all 0 1 2 3 4 5 My chest is completely full of phlegm (mucus)

1

2

3

4

5

My chest does not feel tight at all 0 1 2 3 4 5 My chest feels very tight

1

2

3

4

5

When i walk up a hill or one flight of stairs i am not breathless 0 1 2 3 4 5 When i walk up a hill or one flight of stairs i am very breathless

1

2

3

4

5

I am not limited doing any activities at home 0 1 2 3 4 5 I am very limited doing activities at home

1

2

3

4

5
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

Your Details

COPD Review

COPD Assessment Test (CAT)

Modified MRC Dyspnea Scale