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


Alcohol Consumption

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? *


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

Please visit for advice on qutting smoking.



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
Please specify: *
Have you taken any antibiotics/steroids in the last year?
Have you been admitted into hospital in the last year?

Further Questions

Please visit the following links for further information on COPD that you may find useful: