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Church Road Surgery and Tile Cross Surgery NHS GP Surgery in Birmingham

COPD review

COPD Assessment

Section

Height:

Weight:

Smoking Status

Do you currently smoke?

Yes

No

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Smoking cessation support is available at the practice, through local pharmacies and via the NHS website.

If you would like to consider giving up smoking in future, please contact the surgery who will be able to offer support.

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

0

1

2

3

4

5

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

0

1

2

3

4

5

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

0

1

2

3

4

5

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) *

0

1

2

3

4

5

Activities

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

0

1

2

3

4

5

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) *

0

1

2

3

4

5

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

0

1

2

3

4

5

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

0

1

2

3

4

5

If you are human, leave this field blank.

Church Road Surgery
90 Church Road
Sheldon
Birmingham
B26 3TP

Get directions

0121 741 1101

Tile Cross Surgery
144 Tile Cross Road
Tile Cross
Birmingham
B33 0LU

Get directions

0121 788 2020

About the surgery

Register with the surgery

Sick (fit) notes

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