COPD Review COPD Review Please complete the online form below to submit your COPD Review First Names Surname Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Please answer the questions below:The first 8 questions below work on a sliding scale, from 0 to 5. Please answer these questions dependent on the severity of your condition.1. The question below helps us to quantify the impact of COPD symptoms on your overall health and form the COPD Assessment Test (CAT), which is a trademark of the GSK grroup. Coughing: I never cough (0) (1) (2) (3) (4) I cough all the time (5) 2. Phlegm I have no phlegm (mucus) on my chest at all (0) (1) (2) (3) (4) My chest is full of phlegm (mucus) (5) 3. Chest My chest does not feel tight at all (0) (1) (2) (3) (4) My chest feels very tight (5) 4. Breathlessness When I walk up a hill or a flight of stairs I am not out of breath (0) (1) (2) (3) (4) When I walk up a hill or a flight of stairs I am completely out of breath (5) 5. Activities I am not limited to doing any activities at home (0) (1) (2) (3) (4) I am completely limited to doing all activities at home (5) 6. Confidence I am confident leaving my home despite my lung condition (0) (1) (2) (3) (4) I am not confident leaving my home at all because of my lung condition (5) 7. Sleep I sleep soundly (0) (1) (2) (3) (4) I do not sleep soundly because of my lung condition (5) 8. Energy I have lots of energy (0) (1) (2) (3) (4) I have no energy at all (5) 9. How breathless do you currently get? Not troubles by breathlessness except on strenuous exercise Short of breath when hurrying or walking up a slight hill Walking slower than contemporaries on level ground because of breathlessness, or have to stop for breath when walking at own pace Stop for breath after walking 100m or after a few minutes on level ground Too breathless to leave the house, or breathless when dressing or undressing 10. Do you use inhalers for your breathing? No Yes, a Metered Dose Inhaler (eg clenil, QVar, seretide evohaler, fostair, flutiform) Yes, an Accuhaler Yes, an Autohaler Yes, a Breezhaler Yes, an Easi-Breathe Yes, an Easyhaler Yes, an Ellipta Yes, a Forspiro / Airflusal Yes, a Genuair Yes, a Handihaler (Spiriva) Yes, a NEXThaler Yes, a Respimat Yes, a Spiromax Yes, a Turbohaler (e.g. symbicort, pulmicort, bricany) If you do and your inhaler contains a steroid, brush your teeth or rinse your mouth with water and spit it out after every use to prevent mouth infections.11. Have you had a breathing exacerbation in the last year? No, I have not had any exacerbations (0) Yes, I have had one exacerbation (1) Yes, I have had 2 or more exacerbations An exacerbation (flare-up) is when your symptoms get suddenly worse – coughing up phlegm, tight chest and breathlessness. They often need additional treatment such as steroids and antibiotics, and are especially common in the winter.12. Do you have steroid tablets at home in case your condition worsens suddenly? Yes, I have steroid tablets at home No, I don’t have steroid tablets at home 13. Do you have antibiotic medication at home in case your condition worsens suddenly? Yes, I have antibiotic medication at home No, I don’t have antibiotic medication at home 14. Do you smoke? Never smoked Ex smoker Trivial smoker (less than one cigarette per day) Light smoker (1-9 cigarettes per day) Moderate smoker (10 – 19 cigarettes per day) Heavy smoker (20 – 39 cigarettes per day)
