COPD monitoring

Section

Assessment

Coughing

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

Phlegm

Tightness

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) *

Activities

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

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) *

Sleep

Energy

Total Score

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

Do you have any problems with your inhaler?

Yes

No

Please contact the surgery to speak to a nurse.

MRC Breathlessness Scale

Please select the one that applies to you:

Not troubled by breathlessness except on strenuous exercise

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

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

Stops for breath after walking about 100 yds or after a few minutes on level ground

Too breathless to leave the house, or breathless when undressing

Would you be interested in Pulmonary Rehabilitation? (this is specific exercises to improve your breathing)

Yes

No

Do you currently smoke?

Yes

No

How many cigarettes do you smoke daily?

Would you like smoking cessation advice?

Yes

No

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