COPD review

Please use this page to submit information in preparation for your telephone review. This will help us carry out the reviews more efficiently and be better able to focus on any areas of your COPD care that require more attention. Click submit at the end of the form – this will send us a secure email which we can then use to transfer the information to your records.

We appreciate this form may take a bit of time to go through – we have tried to keep it as brief as possible and anticipate that most people should be able to complete it within 10-15 minutes.

COPD questionnaire

Name*
First Last
Date of birth*
MM slash DD slash YYYY
Number of emergency attendances for acute flare-ups of your condition in the last 12 months?*

Please include visits to GP, walk-in clinic, urgent care centre, A+E, and hospital admissions. If you are not sure exactly, give an approximation.
Number of courses of oral steroids (prednisolone) prescribed in the last 12 months?*

Give an approximation if you are not sure.
Number of courses of antibiotics prescribed for your chest in the last 12 months?*

Give an approximation if you are not sure.
Have you ever been prescribed a rescue pack? (An emergency standby pack of steroids +- antibiotics for flare-ups)*
Do you currently possess an in-date supply of your normal rescue pack medication (s)?*
Hygiene
- I have viewed and am happy with the guidance
Please see the following guidance on hygiene: https://www.nhs.uk/live-well/healthy-body/best-way-to-wash-your-hands/ and tick the above box to confirm understanding
Social Distancing
- I have viewed and am happy with the guidance
Please see the following guidance on social distancing https://www.nhs.uk/conditions/coronavirus-covid-19/social-distancing/what-you-need-to-do/ and tick the above box to confirm understanding
Are you managing in general and, if applicable, feel that you have adequate social support?*
Smoking history*
Please select which one describes you best.
Smoking cessation
- I intend to stop smoking and will consider the information in the link
If you are a smoker currently, please look at the following information https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/ and tick above if you wish pursue efforts to stop smoking
Personalised self-management plan
Max. file size: 128 MB.
If you are in possession of a self-management plan, then please scan and attach it here if you are able to.
Influenza (Flu) Vaccination*
Please indicate if you have had the flu jab since the most recent September
Pneumonia Vaccination*
Please indicate here if you recall having had this (usually one-off vaccination)
Please list your medication for COPD and the frequency and number of puffs/tablets you take each time
Describe your inhaler technique (as if you were teaching someone how to use one correctly)
If you have more than one device the please provide a description for each type of inhaler.
Do you use a spacer/aerochamber device when using your inhaler?*
We will ask you to describe your inhaler technique over the phone. Studies suggest that only 10% of patients use their inhaler correctly. Please refer to the following resource for further information https://www.asthma.org.uk/advice/inhaler-videos/
Do you use a nebuliser at home which you have needed to use in the last year?*
Are you receiving prescribed supplementary oxygen at home?*
Exercise capacity
Please select the option the best describes you
Pulmonary rehabilitation

If you have under-gone this before, please state the year (s) and whether you found it helpful.
Shielding
- I am happy and aware of the government advice on shielding
If you are in the shielding group, you may have received a letter from the government. Please refer to the following guidance for up to date information https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 and/or tick to confirm you are happy and aware of the advice
Self-Isolation
- I am happy and understand the guidance
Please refer to this guidance to confirm correct understanding of the rules on self-isolation https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection and tick to confirm you are happy and understand the guidance.
I never cough
I have no phlegm/mucus in my chest at all.
My chest does NOT feel tight at all
When walking uphill or up a flight of stairs I am NOT breathless at all.
I am NOT limited doing any activities at home
I am confident leaving my home despite my lung condition
I sleep soundly
I have lots of energy
Comments
This field is for validation purposes and should be left unchanged.

27458

Update your Details

Order your Prescriptions

Online Appointment Booking

Patient Participation Group

Download Practice Leaflet

Friends and Family Test

Print Blood Forms

Add Clinical Data BP/Smoking/Weight etc

Opening Times

Monday
08:00am to 06:30pm
Extended hours appointments (pre-booked only) 18:30-19:00
Tuesday
08:00am to 06:30pm
Extended hours appointments (pre-booked only) 18:30-19:00
Wednesday
08:00am to 06:30pm
Extended hours appointments (pre-booked only) 18:30-19:00
Thursday
08:00am to 06:30pm
Extended hours appointments (pre-booked only) 18:30-19:00
Friday
08:00am to 06:30pm
Extended hours appointments (pre-booked only) 18:30-19:00
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Western Road Medical Centre

COPD review

COPD questionnaire

Opening Times

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

Western Road Medical Centre

COPD review

COPD questionnaire

Opening Times

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

Privacy settings

With the slider, you can enable or disable different types of cookies:

This website will:

This website won't:

This website will:

This website won't:

This website will:

This website won't:

This website will:

This website won't: