Age: | |
Smoking status: | |
"Do you cough regularly?" | |
"Do you cough up plegm regularly?" | |
"Do even simple chores make you short of breath?" | |
"Do you wheeze when you exert yourself, or at night?" | |
"Do you get frequent colds that persist longer than those of other people?" | |
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Status: |
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Format: |
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Number of cigarettes per day: | |
Year Started: | |
Year Stopped: | |
Number of Years Smoking: | |
Pack Years: |
Have you ever had: |
Hayfever
Eczema Asthma |
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Family history of: |
Hayfever
Eczema Asthma |
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Breathlessness Frequency: |
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Cough: |
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Sputum: |
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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" |
Height: | cm |
FEV1: | Actual: (L) Predicted: (L) % of Predicted: % |
FVC or FEV6: | Actual: (L) Predicted: (L) % of Predicted: % |
Ratio FEV1:FVC or FEV1:FEV6: | % |
Add classifcation of COPD (H3)
“Living Positively with COPD” provided Add 3 year recall Save to Daily Record |