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COPD Review Form

Forth Medical Group > Your Record > Health Review Forms > COPD Review Form
COPD Review
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Please use format day/month/year e.g. 12/05/1979

COPD Review

How breathless are you? *
How many times have you been admitted to hospital in the past year with your chest? *
How many courses of antibiotics and steroids have you had in the last year for your COPD? *
Do you have a COPD self-management plan? *
Do you have a COPD alert card? *
Do you have standby antibiotics and steroids at home as part of your treatment plan? *
Do you have any specific issues with your COPD which you would like to discuss further? *

Height Weight and BMI

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Lifestyle

1 unit = 1 small glass of wine, half pint of beer/lager, single measure of spirit/whisky/vodka etc
Do you smoke? *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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