COPD Review Form

Please only complete the following questionnaire if requested by your GP practice as part of your routine COPD review.

This questionnaire is for a routine review of your COPD symptoms. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Last Updated: 09/02/2022

Your Details

Which surgery are you registered with? *

Name *

Date of Birth *

Phone Number *

Email Address *

COPD Review

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly:

COPD Foundation Videos - https://www.copdfoundation.org/Learn-More/For-Patients-Caregivers/Educational-Video-Series/Inhaler-Training-Videos.aspx

I have watched the above relevant inhaler technique videos and am happy with my inhaler technique

Yes No

Lifestyle - Alcohol

Lifestyle - Smoking

Further Question

I have the following questions that I would like to raise with my COPD Nurse or Doctor:

Further Information

Please see the following links for further information on COPD that you may find useful:

NHS - http://www.nhs.uk/conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx

Patient.Info - http://patient.info/health/chronic-obstructive-pulmonary-disease-leaflet

British Lung Foundation - https://www.blf.org.uk/support-for-you/copd

COPD Assessment Test Score

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled.

Please select a score of 0 to 5 to help assess the severity of your symptoms.

COPD Assessment Test Score

Add up the total for questions 1 to 8.

Very High: If your score is >30 - There is significant room for improvement in the management of your COPD

High: If your score is 20-30 - There is room for improvement in the management of your COPD

Medium: If your score is 10-20 - There is room for optimisation in the management of your COPD

Low: If your score is <10 - Your COPD is well managed at present

Consent and Submit

When you are happy with all your above answers, please click 'Submit form' below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and your other medical conditions, you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

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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COPD Review Form

Further Information