When we are closed please call 111 for all health advice. A&E is for EMERGENCIES only - please use services carefully - call 111 when we are closed for the out of hours services!! NEW SERVICE!!!! Dr Gowda is offering a coil and implant fitting service, ask your GP for more details

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COPD Health Questionnaire

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Title *
Mr Mrs Miss Ms Other
Name * First Last
Date of Birth * / DD / MM YYYY
Gender *
Male Female
Address *

Street Address Address Line 2 Town/City County/Region Postcode Country
Email *
Home/Main Phone Number *

If you do not have a home telephone number please enter your main contact telephone number here instead.
Work Phone Number
Mobile Phone Number

Please think carefully about the following questions. For example, question 1 - I never cough - if you never cough, tick the column headed 0, if you cough but very rarely, tick column marked 1 - if you are coughing all the time, then tick the end column marked 'complete opposite of statement' *
	0	1	2	3	4	5	Complete opposite of statement
I never cough
I have no phlegm (mucus) in my chest at all
My chest does not feel tight at all
I am not limited to doing any activities at home
I am confident leaving leaving my home despite my lung condition
I sleep soundly

Now please think about how breathless you are when doing the following and click the ONE answer that best describes how you usually are *
Not troubled by breathlessness except on strenuous exercise Short of breath when hurrying up a slight hill Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace. Stops for breath after about 100m or a few minutes on the level Too breathless to leave the house, or breathless when dressing or undressing
Do you smoke?
Yes No
In the last 12 months, have you had to go into hospital because of your COPD?
Yes No
If you answered yes to the question above because you have been admitted to hospital in the last 12 months can you please tell us when and how many times if more than once.
Have you had a rescue pack issued to you in the last 12 months
Yes No
If you answered yes to having a rescue pack, can you tell us when and how many times you have used one in the last 12 months
Do you have a COPD management plan?
Yes No
Finally, if there is anything you would like to tell us about your COPD, please use this box. Our Team will now review your answers and will be in contact with you. It would help if you could download the myGp app onto a mobile phone as then we can video call you to check on how you are. Thank you for your time
Type the letters you see in the image below.