COPD assessment

1. When was your COPD diagnosed? 

2. In the last month, have you had any difficulty sleeping because of your COPD symptoms (including cough)? yesno

Details of sleeping difficulties:

3. In the last month, have you had your usual COPD symptoms during the day? (cough, wheeze, chest tightness or breathlessness)? yesno

Details of symptoms during the day: 

4. In the last month, has your COPD interfered with your usual activities (e.g. housework, work, school etc?) yesno

5. Do you have a oximeter? yesno

If yes, do you know your reading 

6. Have you ever smoked? yesno

If 'Yes', please answer the following:

Do you smoke now? yesno

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

7. What is your current weight? 

COPD Control Score

8. During the past 4 weeks, how often have you had shortness of breath? 

9. During the past 4 weeks, how often did your COPD symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? 

10. During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? 

11. How would you rate your COPD control during the past 4 weeks? 

12. Are you currently under the COPD team? yesno

13. Have you been offered a referral for pulmonary rehab? yesno

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