COPD Review

Please tick to indicate which statement best describes your breathlessness when you are well (not during an exacerbation/infection). *

Breathlessness only with strenuous exercise - 1

Short of breath when hurrying on the level or up a slight hill - 2

Slower than most people of the same age on a level surface or have to stop when walking at my own pace on the level - 3

Stop for breath walking 100 meters or after walking a few minutes at my own pace on the level - 4

Too breathless to leave the house - 5

If you ticked options 3, 4 or 5 you may benefit from Pulmonary Rehabilitation. Pulmonary rehabilitation is a supervised programme that includes exercise, health, education, and breathing techniques for people who have COPD. Would you like to be referred for pulmonary rehabilitation? Please be aware if you have previously been referred or considered unsuitable for Pulmonary Rehabilitation, a further referral will not be offered. *

Yes No

Please indicate your current smoking status. *

Current Smoker

Ex-smoker

Never Smoked

Use e-cigarettes ONLY

If you are a current smoker - how many do you smoke per day? Stopping smoking is the most important step you can take to prevent your COPD getting worse. For help with quitting please contact the Healthy Lifestyles Team on 01952 382582. *

How many times have you had antibiotics and/or steroids when your chest has been bad in the last 12 months? *

If you have not already had your Seasonal Flu vaccination this winter, do you wish to have one? (Flu season is annually between September and March) *

Yes No

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. *

I consent to the practice collecting and storing my data from this form.

Further Information