Asthma & COPD Review RMP

Please only complete this questionnaire if requested by your GP practice as part of your routine Asthma & COPD review.

Last Updated: 14/07/2023

Your Details

Name *

Date of Birth *

Address *

Phone Number *

Email Address *

Respiratory Review

This questionnaire is for your routine review of your COPD symptoms. If you are experiencing shortness of breath at present, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Please select the answer that best describes your breathing *

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a hill

I walk slower than contemporaries (peers) on level ground due to breathlessness or stop if walking at my own pace

I stop for breath when walking 100 yards or after a few minutes on level ground

I am breathless when dressing or am too breathless to leave the house

How many COPD exacerbations (attacks) have you had in the past year? *

How many hospital admissions have you had due to your COPD in the past year? *

Inhaler technique

It is essential to have good inhaler teqnique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly.

COPD Foundation Videos

https://www.copdfoundation.org/Learn-More/Educational-Materials-Resources/Educational-Video-Series.aspx

I have watched the above relevant inhaler technique video and am happy with my inhaler technique *

Yes No

Lifestyle - Smoking

COPD Assessment Test Score

The COPD Assessment Test provides a score to help you and your healthcare provider determine if your COPD symptoms are well controlled.

Please select the score of 0 - 5 to help assess the severity of your symptoms. Please calculate your score and submit your total below.

Asthma Control Test

The Asthma Control Test provides a score to help you and your healthcare provider determine if your asthma symptoms are well controlled.

If you are 12 years or older, please complete the questions below.

Asthma Control Test Score

If your score is 25 or more - Your asthma is well controlled *

Yes No

If your score is 20-24 - Your asthma is reasonably well controlled *

Yes No

If your asthma score is 19 or less - Your asthma is not well controlled *

Yes No

Further Questions and Consent

When you are happy with all your answers, please click submit below and the questionnaire will be automatically sent to your GP practice. Depending on your answers and you other medical conditions, you will be contacted if you need to be seen in clinc for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

I have the following questions that I would like to raise with my respiratory Nurse or GP.

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 *

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Asthma & COPD Review RMP

Further Information