Required field(s) are indicated by * COPD Assessment Review COPD Assessment Review If you are human, leave this field blank. Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: * Email Address: * Any responses we send will go to this email address. Assessment Coughing I never cough Coughing: from 0 (I never cough) to 5 (I cough all the time) * 0 1 2 3 4 5 I cough all the time Phlegm I have no phlegm (mucus) in my chest at all 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 My chest is full of phlegm (mucus) Tightness My chest does not feel tight at all Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) * 0 1 2 3 4 5 My chest feels very tight Stairs When I walk up a hill or one flight of stairs I am not breathless 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 When I walk up a hill or one flight of stairs I am very breathless Activities I am not limited doing any activities at home 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 I am very limited doing any activities at home Leaving I am confident leaving my home despite my lung condition 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 I am not at all confident leaving my home despite my lung condition Sleep I sleep soundly Sleep: from 0 (I sleep soundly) to 5 (I don't sleep soundly because of my lung condition) * 0 1 2 3 4 5 I don't sleep soundly because of my lung condition Energy I have lots of energy Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) * 0 1 2 3 4 5 I have no energy at all Additional Information Please let us know if you have anything COPD related that you would like to discuss as part of this review: * I confirm I have been asked to complete this review form by the nurse/a clinician.
