COPD Assessment

If you have been advised by the surgery to submit a COPD assessment please use this form.

This assessment will help us measure the impact of COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your score will be used by us to help improve the management of your COPD and get the greatest benefit from treatment.

COPD Assessment
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.


Degree of breathlessness related to activities *
Anyone selecting the third question, or above, on this scale is usually offered pulmonary rehabilitation. This is suspended during the Covid-19 pandemic.

Smoking Status: *
We would strongly encourage you have your annual flu vaccination to reduce the risk of complicated asthma exacerbations and chest infections:

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *