COPD questionnaire

Name

Date of birth

E mail

Telephone number

Mobile number

How often do you cough?

How much phlegm do you feel you have on your chest?

How tight is your chest?

When do you get out of breath?

How out of breath do you get?

How much are you limited by your COPD when at home?

How confident do you feel leaving your home with your lung condition?

How well do you sleep?

How much energy do you have?

How many COPD exacerbations have you had in the past 12 months?An exacerbation is where your breathlessness or cough got worse and you needed to take a rescue pack of seek medical attention

Did you go into hospital because of any COPD exacerbations?An exacerbation is where your breathlessness or cough got worse and you needed to take a rescue pack of seek medical attention

What medication are you taking?

What is your smoking status?

If you are a current smoker, how much do you smoke?

How many years have you smoked for?

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Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Newbury Group Practice • Newbury Park Health Centre, 40 Perrymans Farm Road, Newbury Park, IG2 7LE.

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