Wareham Surgery

This questionnaire will help you and your healthcare professional measure the impact COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your answers, and test score, can be used by your healthcare professional to help improve the management of your COPD and get the greatest benefit from treatment.

For each item below, please rate between 0 and 5 which best describes you currently.
Name*
Date of Birth*
DD slash MM slash YYYY
Email*
How often do you cough?*
Please enter a number from 0 to 5.
0 = I never cough, 5 = I cough all the time
Do you have phlegm on your chest?*
Please enter a number from 0 to 5.
0 = I have no phlegm (mucus) In my chest at all, 5 = My chest is completely full of phlegm (mucus)
Do you have chest tightness?*
Please enter a number from 0 to 5.
0 = My chest does not feel tight at all, 5 = My chest feels very tight
Do you get breathless on an incline?*
Please enter a number from 0 to 5.
0 = When I walk up a hill or one flight of stairs I am not breathless, 5 = When I walk up a hill or one flight of stairs I am very breathless
Are you limited when doing activities?*
Please enter a number from 0 to 5.
0 = I am not limited doing any activities at home, 5 = I am very limited doing activities at home
Are you confident to leave the house?*
Please enter a number from 0 to 5.
0 = I am confident leaving my home despite my lung condition, 5 = I am not at all confident leaving my home because of my lung condition
How do you sleep?*
Please enter a number from 0 to 5.
0 = I sleep soundly, 5 = I don’t sleep soundly because of my lung condition
Do you have energy?*
Please enter a number from 0 to 5.
0 = I have lots of energy, 5 = I have no energy at all
Please choose the one best response to describe your shortness of breath:*
- 0 - “I only get breathless with strenuous exercise”
- 1 - “I get short of breath when hurrying on the level or walking up a slight hill”
- 2 - “I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level”
- 3 - “I stop for breath after walking about 100 yards or after a few minutes on the level”
- 4 - “I am too breathless to leave the house” or “I am breathless when dressing”
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Tuesday
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14:00 until 18:30
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14:00 until 18:30
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