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St James Medical Practice NHS GP Surgery in King’s Lynn, West Norfolk

COPD review

You will need to enable JavaScript or use a browser that supports JavaScript to use the service.Find out how to enable JavaScript for Windows, or how to enable JavaScript for Mac.You can also contact the surgery on 01553 774 221 during opening times. If you need help right now, use the NHS 111 service. In an emergency, call 999 or go to A&E.

COPD Assessment

Section

Alcohol Consumption

Please visit www.drinkaware.co.uk/tools/unit-and-calorie-calculator

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times a month

2-3 times a week

4 times or more a week

How many units of alcohol do you drink on a typical day drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Smoking

Do you smoke?

Yes

No

Please specify: *

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette?

Yes

Ex-user

No

Would you like help to quit smoking?

Yes

No

Please visit www.nhs.uk/smokefree for advice on qutting smoking.

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

0

1

2

3

4

5

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

0

1

2

3

4

5

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

0

1

2

3

4

5

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

0

1

2

3

4

5

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

Please specify: *

I am 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 100 yards or after a few minutes of walking on level ground

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

Have you taken any antibiotics/steroids in the last year?

Yes

No

Have you been admitted into hospital in the last year?

Yes

No

Further Questions

I have the following questions that I would like to raise with my COPD Nurse or Doctor:

Please visit the following links for further information on COPD that you may find useful:

NHS: Chronic Obstructive Pulmonary Disease
Patient Info: Chronic Obstructive Pulmonary Disease
British Lung Foundation: Support for your COPD

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Edward Benefer Way
South Wootton
Kings Lynn
Norfolk
PE30 2FQ

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01553 774 221

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