COPD Review Form

This form is used for your annual COPD review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or a Doctor.

Last Updated: 15/12/2021

Conditions of Use

1. THIS FORM IS FOR THE SAFE AND EFFICIENT MANAGEMENT OF REPEAT PRESCRIPTIONS ONLY. THIS FORM SHOULD ONLY BE USED WHEN DIRECTED TO DO SO BY A MEMBER OF THE PRESCRIPTION MANAGEMENT TEAM. ANY OTHER REQUESTS MADE ON THIS FORM WILL BE IGNORED. *

I confirm that I have read the conditions of use

Your Details

Forename *

Surname *

Date of Birth *

Mobile Phone Number *

Email Address

APPROXIMATELY HOW MANY UNITS OF ALCOHOL DO YOU DRINK EACH WEEK? *

1-5

6-10

11-15

15+

Height (if known)

Weight (if known)

Blood Pressure

IF YOU HAVE A BLOOD PRESSURE MACHINE, PLEASE ENTER YOUR BLOOD PRESSURE BELOW

Smoking

Do you currently smoke? *

Yes No

COPD Assessment Test (CAT)

Please answer each question by giving a score from 0-5

Breathlessness Review

Please be aware that a nurse may contact you to discuss your COPD review

HOW DO YOU RATE YOUR LEVEL OF BREATHLESSNESS? *

I’m not troubled by breathlessness

I get breathless when I undertake vigorous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after a few minutes of walking a short distance on level ground

I’m too breathless to leave the house and get breathless when getting dressed

Inhalers

PLEASE LIST THE INHALERS YOU USE DAILY OR ON A REGULAR BASIS (NAME/STRENGTH/HOW MANY PUFFS/HOW MANY TIMES A DAY/VIA A SPACER DEVICE?) *

Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

I consent to the practice collecting and storing my data from this form

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COPD Review Form

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