COPD Assessment

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

This assessment 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 Assessment

COPD Assessment

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

You are due for a review because you have a diagnosis of COPD (Also called Chronic Obstructive Lung Disease or Emphysema).

Please answer the following questions about your COPD. The answers you give will help us to begin to review your COPD and decide how urgently you need to speak to a practice nurse.

Understanding Your COPD

Information to help people understand their lung condition is available at www.uhdb.nhs.uk/pulmonary-rehabilitation-information-on-your-lung-condition. You may wish to look at this before completing this form. 

Do you feel that you understand your lung condition? *
Do you consent to us sending you information about your condition by SMS messaging to your mobile phone if appropriate? *

Smoking

Do you currently smoke? *
Do you wish to be sent details of how to access support to help you quit?

Flu Vaccination

Have you had your annual flu vaccination this year? *
Would you like us to arrange for you to have a flu vaccine? *

Weight

Your Treatment

Inhaler Technique

It is important to use inhalers correctly so that you get full benefit.

Videos showing how to use different types of inhaler are available on this website: www.asthma.org.uk/advice/inhaler-videos

Do you use a spacer? *
A plastic chamber which you attach to your inhaler.
Have you replaced it in the last 12 months? *
If no we will send a prescription for a new one to your usual pharmacy.
Are you having any problems with your medication/ inhalers? *

COPD Symptom Review

Have you been admitted to hospital during the last 12 months, because of your COPD? *
Which of the following best described your level of breathlessness relating to activity? *

CAT Test Score

The COPD Assessment Test (CAT Test) is a questionnaire for people with COPD. It is designed to measure the impact of COPD on a person's life, and how this changes over time.

For each item below, please choose the box that best describes your health currently.

Be sure to only select one response for each question.

Example: I am very happy 0 1 2 3 4 5 I am very sad. A score of 1 would show that you feel far closer to the “I am very happy” statement.

I never cough
I cough all the time
My chest is full of phlegm (mucus)
My chest is full of phlegm (mucus)
My chest does not feel tight at all
My chest feels very tight
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
I am not limited doing any activities at home
I am very limited doing any activities at home
I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition
I sleep soundly
I don't sleep soundly because of my lung condition
I have lots of energy
I have no energy at all