COPD AssessmentYour Full Name*Your Date of Birth*In general how often do you cough?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I never cough' to 5 being 'I cough all the time'.Generally how clear is your chest?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I have no phlegm (mucus) in my chest' to 5 being 'My chest is completely full of phlegm (mucus)'Generally speaking, how tight is your chest?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'my chest does not feel tight' to 5 being 'my chest feels very tight'.How breathless do you get?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'when I walk up a hill or one flight of stairs I am not breathless' to 5 being 'when I walk up a hill or one flight of stairs I am very breathless'.How limited are you by your COPD when doing activities at home?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I am not limited doing activities at home' to 5 being 'I am very limited doing activities at home'.How confident are you when you go out?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I am confident leaving my home despite my lung condition' to 5 being 'I am not at all confident leaving my home because of my lung condition'.How much does your COPD affect your sleep?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I sleep soundly' to 5 being 'I do not sleep soundly because of my lung condition'.In general, how much energy do you have?* 0 1 2 3 4 5Please score yourself from the options above: 0 being 'I have lots of energy' to 5 being 'I have no energy at all'.Please choose your current smoking status from the drop down list below*Never SmokedEx SmokerCurrent SmokerReady/thinking about stopping smokingWould rather not give smoking statusIf you are ready or thinking about stopping smoking for further information and support please visit our NHS Smokefree Support Service page which can be found under the Services heading on our main menu.
