COPD Review Form

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 with the Asthma nurse or a Doctor as well.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Breathlessness

    Please select the answer that best describes the level of your breathlessness
    Do you smoke? (optional)
    Did you have a flu vaccination last flu season? (optional)

  • Well being and daily life

    For each question, please give a score on a scale of 0 and 5 that best describes you currently. 0 being the best and 5 being worst. Example "I am quite happy" would score 2 and "I am very unhappy" would score 5

    Contact Permissions (optional)
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION & MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU & 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
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Page last reviewed: 04 September 2020
Page created: 10 December 2019