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COOD Questionnaire

Required fields are marked with an asterisk (*).

This Questionnaire is to review your COPD, and your practice may not see this report for up to 7 days. If you have severe symptoms, please contact the practice directly for urgent appointment or call 111

Name

First

Last

Date of Birth*

Email address*

Phone Number*

NHS Number

1. How often do you cough?*

0 – I never cough

5 – 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 all

5 – My chest is full of phlegm (muscus)

3. How tight is your chest?*

0 – My chest does not feel tight at all

5 – 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 breath

5 – When I walk up a hill or 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 exercise

2 – Short of breath when hurrying, or walking up a slight hill

3 – 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 pace

4 – I get short of breath after walking 100 yards or after a few minutes on level ground

5 – 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 home

5 – I am completely limited to doing all activities at home

Website URL*

7. How confident do you feel leaving your home with your lung condition?*

0 – I am confident leaving my home despite my lung condition

5 – 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 night

5 – I do not sleep soundly because of my lung condition

9. How much energy do you have?*

0 – I have lots of energy

5 – I have no energy at all

10. How many COPD exacerbation’s 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?*

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

Yes

12. What is your smoking status?*

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’.

Current smoker

Ex-smoker

Never smoked

13. How much did you used to smoke?*

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.

<1 cigarettes or equivalent per day

1-9 cigarettes or equivalent per day

10-19 cigarettes or equivalent per day

20-39 cigarettes or equivalent per day

40+ cigarettes or equivalent per day

14. How many years did you used to smoke for?*

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.

I consent to the practice collecting and storing my data from this form

Are you human?*