Asthma & COPD Review RMP

Please only complete this questionnaire if requested by your GP practice as part of your routine Asthma & COPD review.

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Address

Phone Number

Email Address
Respiratory Review

This questionnaire is for your routine review of your COPD symptoms. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Please select the answer that best describes your breathing

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a hill

I walk slower than contemporaries (peers) on level ground due to breathlessness or stop if walking at my own pace

I stop for breath when walking 100 yards or after a few minutes on level ground

I am breathless when dressing or am too breathless to leave the house

How many COPD exacerbations (attacks) have you had in the past year?

How many hospital admissions have you had due to your COPD in the past year?
Inhaler technique

It is essential to have good inhaler teqnique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly.

COPD Foundation Videos

https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Educational-Video-Series.aspx

I have watched the above relevant inhaler technique video and am happy with my inhaler technique

Yes

No
Lifestyle - Smoking

Do you smoke?

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 or vape?

Yes

No

If you smoke, would you like help to quit smoking? (For further information, please see www.nhs.uk/smokefree) (optional)

Yes

No
COPD Assessment Test Score

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled.

Please select the score of 0 - 5 to help assess the severity of your symptoms. Please calculate your score and submit your total below.

Cough

0 - I never cough

1

2

3

4

5 - I cough all the time

Phlegm/Mucous

0 - I have no phlegm (mucus) in my chest at all

1

2

3

4

5 - My chest is completely full of phlegm

Chest Tightness

0 - My chest does not feel tight

1

2

3

4

5 - My chest feels very tight

Breathlessness

0 - When I walk up a hill or one flight of stairs I am not breathless

1

2

3

4

5 - When I walk up a hill or one flight of stairs I am very breathless

Activities

0 - I am not limited at all doing any activities at home

1

2

3

4

5 - I am very limited doing activities at home

Confidence

0 - I am confident leaving my home despite my lung condition

1

2

3

4

5 - I am not at all confident leaving my home because of my lung condition

Sleep

0 - I sleep soundly

1

2

3

4

5 - I don't sleep soundly because of my lung condition

Energy

0 - I have lots of energy

1

2

3

4

5 - I have no energy at all

COPD Assessment Test Score

VERY HIGH - If your score is > 30 - There is significant room for improvement in the management of your COPD

HIGH - If your score is 20-30 - There is room for improvement in the management of your COPD

MEDIUM - If your score is 10-20 - There is room for optimisation in the management of your COPD

LOW - If your score is <10 - Your COPD is well managed at present
Asthma Control Test

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled.

If you are 12 years or older, please complete the questions below.

How often did your asthma prevent you from getting as much done at work/school/home?

All of the time - 1

Most of the time - 2

Some of the time - 3

A little of the time - 4

None of the time - 5

How often have you had shortness of breath?

More than once a day - 1

Once a day - 2

3-6 times a week - 3

1-2 times a week - 4

None at all - 5

How often did your asthma symptoms wake you up at night or early in the morning?

4 or more times - 1

2-3 nights a week - 2

Once a week - 3

Once or twice - 4

Not at all - 5

How often have you used your reliever inhaler (usually blue)?

3 or more times a day - 1

1-2 times a day - 2

2-3 times a week - 3

Once a week or less - 4

Not at all - 5

How would you rate your asthma control?

Not controlled - 1

Poorly controlled - 2

Somewhat controlled - 3

Well controlled - 4

Completely controlled - 5
Asthma Control Test Score

If your score is 25 or more - Your asthma is well controlled

Yes

No

If your score is 20-24 - Your asthma is reasonably well controlled

Yes

No

If your asthma score is 19 or less - Your asthma is not well controlled

Yes

No
Further Questions and Consent

When you are happy with all your answers, please click submit below and the questionnaire will be automatically sent to your GP practice. Depending on your answers and you other medical conditions, you will be contacted if you need to be seen in clinc for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

I have the following questions that I would like to raise with my respiratory Nurse or GP. (optional)

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

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Asthma & COPD Review RMP

Asthma & COPD Review RMP

Your Details

Respiratory Review

Inhaler technique

Lifestyle - Smoking

COPD Assessment Test Score

Asthma Control Test

Asthma Control Test Score

Further Questions and Consent