COPD review

Section

Systolic Blood Pressure Reading (if known):

Number at the top.

Diastolic Blood Pressure Reading (if known):

Number on the bottom.

Heart Rate (if known):

Weight: *

Kg, Stone, Lbs.

How many chest infections have you had in the last year? *

Do you have a rescue pack? *

Yes

No

Do you know when to use the rescue pack? *

Yes

No

British Lung Foundation

For more information about COPD, Inhaler Techniques and Self Management Tools, please visit www.blf.org.uk/support-for-you/copd/health-care-professionals.

Assessment

Coughing

Phlegm

Tightness

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)

Activities

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

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)

Sleep

Energy

Total Score

This is automatically calculated and will be sent to the practice upon submission.

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