COPD
Questionnaire

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COPD Questionnaire

Required fields are marked with an asterisk (*).

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

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

Please note that ‘smoking status’ refers to smoking tobacco products, and NOT the use of e-cigarettes or ‘vaping’. If you only use e-cigarettes or ‘vape’ then please select ‘Ex-smoker’ (if you used to smoke tobacco products) or ‘Never smoked’.

If you used to 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 select your best guess.

Privacy Consent – This form collects personal and medical information about you/ We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage submitted data.

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