COPD Questionnaire

As part of your care your GP would like to gather up-to-date information about some aspects of your COPD. It should not take longer than five minutes to complete.

1. How often do you cough?*
0 - I never cough12345 - I cough all the time

2. How much phlegm do you feel you have on your chest?*
0 - I have no phlegm (mucus) on my chest at all12345 - My chest is full of phlegm (mucus)

3. How tight is your chest?*
0 - My chest does not feel tight at all12345 - My chest feels very tight

4. When do you get out of breath?*
0 - When I walk up a hill or a flight of stairs I am not out of breath12345 - When I walk up a hill or a flight of stairs I am completely out of breath

5. How out of breath do you get?*
1 - Not troubled by breathlessness except on strenuous exercise2 - Short of breath when hurrying or walking up a slight hill3 - I walk slower than people the same age on level ground because of breathlessness, or I have to stop for breath when walking at my own pace4 - I get short of breath after walking 100 yards or after a few minutes on level ground5 - I am too breathless to leave the house or breathless when dressing or undressing

6. How much are you limited by your COPD when at home?*
0 - I am not limited to doing any activities at home12345 - I am completely limited to doing all activities at home

7. How confident do you feel leaving your home with your lung condition?*
0 - I am confident leaving my home despite my lung condition12345 - I am not confident leaving my home at all because of my lung condition

8. How well do you sleep?*
0 - I sleep soundly at night12345 - I do not sleep soundly because of my lung condition

9. How much energy do you have?*
0 - I have lots of energy12345 - I have no energy at all

10. How many COPD exacerbations have you had in the past 12 months?*

An exacerbation is where your breathlessness or cough got worse, and you needed to take a rescue pack or to seek medical attention.

11. Did you go into hospital because of any COPD exacerbations?*
YesNo

12. What is your smoking status?*
Current smokerEx-smokerNever smoked

13. How much do you smoke?*

If you smoke something other than traditional cigarettes (e.g. roll-your-own or cigars) but you aren’t sure what the equivalent in cigarettes is then please just select your best guess.

< 1 cigarettes or equivalent per day1-9 cigarettes or equivalent per day10-19 cigarettes or equivalent per day20-39 cigarettes or equivalent per day40+ cigarettes or equivalent per day

14. How many years have you smoked?*

By using this form you agree with the storage and handling of your data by Lingwell Croft Surgery, in line with the disclaimer.

Other Useful Phone Numbers

Leeds General Infirmary – 0113 243 2799

St James’s Hospital – 0113 243 3144

Allied Pharmacy – 0113 271 3066

Dental Surgery – 0113 270 2820

Get in Touch

0113 270 4848

0113 270 5372

Contact Your Doctors

Find Us

Lingwell Croft Surgery

16 Shelldrake Drive

Middleton

Leeds

LS10 3NB

Practice Geographical Area

The practice covers a geographical area that is centred on the LS South Leeds. It is bordered by Southleigh Road, The Clearings, Belle Isle Circus and Winrose Grove to the north, the A1/M, Middleton Lane (A654) to the south and the disused railway lines to the west.