COPD DIAGNOSIS AND MANAGEMENT

Is Sprimoetry Indicated:

Age:
Smoking status:
"Do you cough regularly?"	Yes No
"Do you cough up plegm regularly?"	Yes No
"Do even simple chores make you short of breath?"	Yes No
"Do you wheeze when you exert yourself, or at night?"	Yes No
"Do you get frequent colds that persist longer than those of other people?"	Yes No
Spirometry recommended for this patient.
Spirometry not indicated for this patient. Record Spirometry anyway

Update Smoking Status:

Status:	Never Smoked Current Smoker Stopped Smoking
Format:	Cigarettes Tobacco
Number of cigarettes per day:
Year Started:
Year Stopped:
Number of Years Smoking:
Pack Years:

Review Previous Spirometry:

Symptom Chart:

Have you ever had:

Hayfever
Eczema
Asthma

Family history of:

Hayfever
Eczema
Asthma

Breathlessness Frequency:

Never

Once a month

Once a week

Daily

Continuously

Cough:

Never

Occasionally

Frequently

Continuosully

Sputum:

Never

Occasionally

Frequently

Continuosully

Record Dyspnoea Scale:

1
"I only get breathless with strenuous exercise"

2
"I get short of breath when hurrying on the level or walking up a slight hill"

3
"I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level"

4
"I stop for breath after walking about 100 yards or after a few minutes on the level"

5
"I am too breathless to leave the house" or "I am too breathless when dressing"

Record Spirometry:

Height:	cm
FEV1:	Actual: (L) Predicted: (L) % of Predicted: %
FVC or FEV6:	Actual: (L) Predicted: (L) % of Predicted: %
Ratio FEV1:FVC or FEV1:FEV6:	%

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