COPD Monitoring

If you have been advised by the surgery to submit a COPD Monitoring form please use this form.

This form will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your score will be used by us to help improve the management of your COPD and get the greatest benefit from treatment.

COPD Monitoring

COPD Monitoring

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Assessment

Coughing

I never cough
I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all
My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless
When I walk up a hill or one flight of stairs I am very breathless

Activities

I am not limited doing any activities at home
I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly
I don't sleep soundly because of my lung condition

Energy

I have lots of energy
I have no energy at all
Do you have any problems with your inhaler?
Please contact the surgery to speak to a nurse.

MRC Breathlessness Scale

Please select the one that applies to you:
Would you be interested in Pulmonary Rehabilitation? (this is specific exercises to improve your breathing)
Do you currently smoke?
Would you like smoking cessation advice?