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Rosedale Surgery NHS GP Surgery in Suffolk

COPD review

COPD Assessment

Section

Smoking status:

Smoker

Ex Smoker

Never Smoked

How many do you smoke in a day?

Would you like to be referred to a smoking cessation adviser?

Yes

No

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

What date did you give up smoking?

How many did you smoke in a day?

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

0

1

2

3

4

5

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

0

1

2

3

4

5

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

0

1

2

3

4

5

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

0

1

2

3

4

5

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

Total Score

This is automatically calculated and will be sent to the practice upon submission.

If you are human, leave this field blank.

Ashburnham Way
Carlton Colville
Lowestoft
NR33 8LG

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01502 505100

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