COPD Review Form

Please complete this form prior to your COPD review

Last Updated: 22/09/2024

About you

Name *

Date of Birth *

Phone number

Since your last review, have you needed to see a doctor as an emergency, as a result of your COPD? *

Yes No

Since your last review, have you needed a course of steroids and/or antibiotics to manage your COPD? *

Yes No

Do you smoke? *

Yes No

Did you have winter vaccinations last season? *

Yes No

CAT (COPD assessment test)

For each question, please tick the option from 0-5 which best describes you currently.

MRC breathlessness scale

Please tick the option that best describes you currently

Breathlessness: *

0 - I only get breathless with strenuous exercise

1 - I get short of breath when hurrying on level ground or walking up a slight hill

2 - On level ground, I walk slower than people of my age because of breathlessness, or I have to stop when walking at my own pace on the level

3 - I stop for breath after walking about 100 yards or after a few minutes on level ground

4 - I am too breathless to leave the house or I am breathless when dressing / undressing

How we process data

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

Yes

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COPD Review Form

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