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The Whitswood Practice NHS GP Surgery in Manchester

COPD review

COPD Assessment

Section

Assessment

Do you currently smoke?

Yes

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Have you smoked in the past?

Yes

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Coughing

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

Phlegm

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

Tightness

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

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

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

Energy

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

Total Score

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

I confirm that I have been advised by a member of staff to complete this assessment

If you are human, leave this field blank.

Alexandra Park Health Centre
2 Whitswood Close
Manchester
M16 7AP

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01612 263 620

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