COPD Questionnaire COPD Questionnaire (COPD010) COPD Questionnaire 0% Complete1 of 2 Patient Name * Patient Name First First Last Last Date of Birth * Address Address Address Address City City County County Postcode Postcode Are you using your blue/reliever inhaler more than once a day? E.g. salbutamol, terbutaline? * YesNo https://www.asthma.org.uk/advice/inhaler-videos/ Here you can view videos to ensure your Inhaler technique is correct. Based on the inhaler technique videos above; How would you class your current inhaler technique? * Inhaler Technique – GoodInhaler Technique – ModerateInhaler Technique – Poor Number of COPD exacerbations in the past year? * Acute exacerbation of COPD An exacerbation is a sustained worsening of the person’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Severity of exacerbation A general classification of the severity of an acute exacerbation is: • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation. MRC Dyspnoea Scale * MRC Dyspnoea Scale: 1MRC Dyspnoea Scale: 2MRC Dyspnoea Scale: 3MRC Dyspnoea Scale: 4MRC Dyspnoea Scale: 5 The MRC breathlessness scale is widely used to describe patient cohorts and stratify them for interventions such as pulmonary rehabilitation in COPD. Please see above Scale. Would you be interested in a COPD Pulmonary Rehab Referral (Applies to MRC Score of 3 or above) * YesNo Pulmonary Rehab is designed for people diagnosed with a lung condition who are breathless. Your PR team will be made up of trained health care professionals such as physiotherapists, nurses and occupational therapists. A course of PR usually lasts 6 to 8 weeks, with 2 sessions of about 2 hours each week. You’ll be in a group of about 8-16 people. PR courses are held in local hospitals, community halls, leisure centres and health centres If you are eligible for COPD Pulmonary Rehab referral please tick which type of service you would prefer Face to Face appointment Online appointment Pulmonary rehabilitation | Asthma + Lung UK (blf.org.uk) Are you a Smoker? * Never Smoked TobaccoLight SmokerModerate SmokerHeavy SmokerVery Heavy SmokerEx-Smoker We strongly advise against smoking. For professional Smoking Cessation Advice please call the free smokefree national helpline on 0300 123 1044 If you are human, leave this field blank. Next