Chronic Obstructive Pulmonary Disease (COPD) Annual Review Questionnaire

If you are a patient of Leander Family Practice and have a diagnosis of COPD you can complete this online form.

The aim of the form is to review your symptoms and the control of your COPD.

First Name

Surname

Date of Birth

Best telephone number to contact you

Address

Post code

Your Current Health

Your smoking status

If you currently smoke, do you want to try to quit or reduce your smoking?If you answer yes we will send you information on the best ways and treatments to help you quit smoking

How many units of alcohol do you consume per day?

Your weightSpecify if in kilograms or stones and pounds

Your heightSpecify if in metres or feet and inches

What is your blood pressure?

If you do not know your blood pressure reading, then please call into the surgery and use our free BP machine located in reception. This will also record your height and weight. No appointment is required. Please ask reception for a gold token to use

Your COPD

How many exacerbations of COPD have you had in the last 12 months?An exacerbation is a flare up of your condition that requires treatments with medication, usually steroids or a rescue pack.

Using the MRC breathlessness scale, please select a grade which you feel represents your current capabilities?

With regards to the above breathlessness score, if you have selected a score of 3 or more you are eligible for a referral to a Pulmonary Rehabilitation Programme – Would you be interested in a referral to the programme?

Do you feel that COPD symptoms and management are well controlled at the moment?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Leander Family Practice • 949 London Road, Thornton Heath, Surrey, CR7 6JE.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.