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.
Date Format: DD slash MM slash YYYY
0 = I never cough, 5 = I cough all the time
0 = I have no phlegm (mucus) In my chest at all, 5 = My chest is completely full of phlegm (mucus)
0 = My chest does not feel tight at all, 5 = My chest feels very tight
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
0 = I am not limited doing any activities at home, 5 = I am very limited doing activities at home
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
0 = I sleep soundly, 5 = I don’t sleep soundly because of my lung condition
0 = I have lots of energy, 5 = I have no energy at all