COPD Assessment

Complete this form if you have been asked to submit a COPD assessment.

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.

You can also use accuRx to submit an online assessment.

Your Details

Title

First Names

Surname

Date of Birth

Home Address

Postcode

Best telephone number to contact you

One of the clinicians will call you on the number provided in the next couple of weeks

Assessment Questions

For each of the following questions please select the option that best describes you now. The scale is between 0 and 5

Your cough

Phlegm (mucus) in your chest

Tightness in your chest

Breathlessness when walking up a hill or one flight of stairs

Activities at home

Confidence in leaving your home

Sleep

Energy levels

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 Prentis Medical Centre • 2 Prentis Road, Streatham, London, SW16 1XU.

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.

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