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Rainbow Medical Centres NHS GP Surgeries in St Helens

COPD review

COPD Assessment

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Assessment

Coughing

Coughing: from 0 (I never cough) to 5 (I cough all the time) *

Phlegm

Phlegm: from 0 (I have no phlegm – mucus – in my chest at all) to 5 (My chest is full of phlegm – mucus) *

Tightness

Tightness: from 0 (My chest does not feel tight at all) to 5 (My chest feels very tight) *

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

Sleep

Sleep: from 0 (I sleep soundly) to 5 (I don’t sleep soundly because of my lung condition) *

Energy

Energy: from 0 (I have lots of energy) to 5 (I have no energy at all) *

If you are human, leave this field blank.

The Sutton Surgery
333 Robins Lane
Sutton
St Helens
Merseyside
WA9 3PN

Get directions

01744 811211

Thatto Heath Surgery
99 Elephant Lane
Thatto Heath
St Helens
Merseyside
WA9 5QL

Get directions

01744 811211

Feedback and complaints

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