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

COPD Assessment


COPD Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine COPD review. 

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

Please select the best description of your cough from the list below: *
Please select the best description of your symptoms at night: *
Please select the best description of your breathing at night: *
Please select any symptoms of swelling (oedema) that apply to you:
Please select the answer that best describes your breathing: *

Inhaler Technique

It is essential to have a good inhaler technique 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: Inhlaer Technique Videos

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

Lifestyle - Alcohol

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day 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? *

Lifestyle - Smoking

Do you smoke? *
Do you use an e-cigarette? *
Would you like help to quit smoking? *

For further information, please visit

COPD Assessment


I never cough
I cough all the time


I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)


My chest does not feel tight at all
My chest feels very tight


When I walk up a hill or one flight of stairs I am not breathless
When I walk up a hill or one flight of stairs I am very breathless


I am not limited doing any activities at home
I am very limited doing any activities at home


I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition


I sleep soundly
I don't sleep soundly because of my lung condition


I have lots of energy
I have no energy at all

Further Questions