COPD review

Which surgery do you normally attend?

Mile End Surgery

Tuckswood Surgery

Gurney Surgery

Section

I have no objections to my email address being added to my medical record as a future form of correspondence. Please note, this will only be used for actions such as sending letters to you or reminding you of reviews and will not be used for any marketing purposes.

Breatlessness Review

Please rate your level of breathlessness:

I am not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after 100 yards or after a few minutes of walking on level ground

I am too breathless to leave the house and get breathless when getting dressed

Assessment

Coughing

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.

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