COPD review

Section

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you give up smoking? *

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

It has been found to be beneficial for patients with COPD to undertake Pulmonary Rehabilitation programmes. You may already have done so. It consists of education about the disease and assistance with exercise.

Please select an option relating to the Pulmonary Rehabilitation programme:

I am interested in taking part in the programme

I have done the programme over 18 months ago and would like to do it again

I have already done the programme within the last 18 months

I am not interested at the current time

Degree of breathlessness related to activities: *

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 yards or after a few minutes on level ground

Too breathless to leave the house, or breathless when undressing

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Section

Smoking

Smoker

Ex Smoker

Assessment

Coughing

Phlegm

Tightness

Stairs

Activities

Leaving

Sleep

Energy