COPD Review - Clackmannan and Kincardine Medical Practice

CDM - COPD

Please complete this COPD review form. This will be reviewed by the Practice Nurse and they will contact you should they feel it is required.

Your Details

Full Name *

Date of Birth *

Mobile Phone Number

Home Phone Number

COPD review

Please confirm you have watched the inhaler technique video *

Yes

Height *

Weight *

HOW DO YOU RATE YOUR LEVEL OF BREATHLESSNESS? *

I’m not troubled by breathlessness except on strenuous exercise

I get short of breath when hurrying or walking up slopes

When walking I have to stop from time to time or walk slower due to breathlessness

I have to stop for breath after a few minutes of walking a short distance on level ground

I’m too breathless to leave the house and get breathless when getting dressed

What is your COPD Assessment Test (CAT) Score? *

If you have a blood pressure monitor, what is your blood pressure reading?

Do you smoke? *

Yes No

If you do smoke, how many do you smoke per day?

If you have an oxygen saturation (SATS) monitor, what is your SATS reading?

How do you rate this online form? *

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. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 01 October 2020
Page created: 03 January 2024

CDM - COPD

CDM - COPD

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