Asthma & COPD Review RMP

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

    Date of Birth
    For example, 15 3 1984
  • 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
  • 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
  • Lifestyle - Smoking

    Do you smoke?
    Do you use an e-cigarette or vape?
    If you smoke, would you like help to quit smoking? (For further information, please see www.nhs.uk/smokefree) (optional)
  • 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
    Phlegm/Mucous
    Chest Tightness
    Breathlessness
    Activities
    Confidence
    Sleep
    Energy
    COPD Assessment Test Score
  • 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?
    How often have you had shortness of breath?
    How often did your asthma symptoms wake you up at night or early in the morning?
    How often have you used your reliever inhaler (usually blue)?
    How would you rate your asthma control?
  • Asthma Control Test Score

    If your score is 25 or more - Your asthma is well controlled
    If your score is 20-24 - Your asthma is reasonably well controlled
    If your asthma score is 19 or less - Your asthma is not well controlled
  • 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. 

     

     

    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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Page last reviewed: 14 July 2023
Page created: 23 August 2022