COPD Annual Review Questionnaire

Name: *

Date of Birth: *

Address:

Postcode: *

Email:

Are you a smoker? *

If yes, Approximately how many cigarettes do you smoke a day? *

If yes, would you like to quit smoking? *

Have you had a chest infection in the last year that required taking oral anti biotics and steroids? *

Are you bringing up any phlegm?

If yes, what colour is the phlegm?

Clear

Yellow

Green

Which of the following best described your level of breathlessness relating to activity (MRC score)

1 – Not troubled by breathless except on strenuous exercise

2 – Short of breath when hurrying on a level or when walking up a slight hill

3 – Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

4 – Stops for breath after walking 100 yards, or after a few minutes on level ground

5 – Too breathless to leave the house, or breathless when dressing/undressing

Please go to the following website and calculate you CAT score. Please give your full score below – https://www.catestonline.org/

Are you happy with your inhaler technique?

Do you use a spacer?

If yes, have you renewed it in the last 12 months?

How many times daily do you use your Salbutamol/Ventolin.blue inhaler?

Pulmonary Rehabilitation is a course of lifestyle/exercise classes run locally for people with breathing problems. They can help and advise on lots of issues including coping strategies or breathlessness, increasing exercise tolerance and peer support. Would you be interested in being referred?

Would you like a flu vaccine this year? *