COPD Annual Review

Thank you for taking time to do your COPD review. Your review will be submitted to a member of our clinical team. It may take approximately 7 days before you will receive confirmation of your COPD review was accepted or whether you need follow up appointment.

Please note that this is annual review, and you will not be asked by us to fill this form more than once a year. However, if your symptoms change or you need further review of your medications please do not hesitate to contact us.

Please note that in some cases you may still be required to attend an appointment if the clinical staff feels that you may need further input into your clinical care.

This form may take you approximately 10 minutes to fill in.

COPD Annual Review

Full name including middle name

Date of Birth

Address including postcode

Email Address

Mobile Number

Medication

1. COPD management medication currently taking

2. COPD management medication currently taking

3. COPD management medication currently taking

4. COPD management medication currently taking

5. COPD management medication currently taking

Clinical information

Height

Weight

Blood pressure

Date Blood Pressure Taken

MRC breathlessness scale

Do you feel you need assistance in reviewing your inhaler technique (how well and effectively you use your inhaler each time)http://www.asthma.org.uk/advice/inhaler-videos/

Smoking status

Smoking cessationPlease note that if you are interested to pursue stopping smoking, the surgery nurses can support you on your journey to become a non-smoker. We will contact you to get you on the right track.

Rescue Pack at Home

COPD - Self Assessment

On Scale of 0 - 5 (0 the least) - How often do you Cough? (select only one answer)

On Scale of 0 - 5 (0 the least) - Do you have any phlegm (mucus) on your chest? (select only one answer)

On Scale of 0 - 5 (0 the least) - Does your chest feel tight at all? (select only one answer)

On Scale of 0 - 5 (0 the least) - Are you limited doing any activity at home? (select only one answer)

On Scale of 0 - 5 (0 the least) - Are you confident leaving your home despite your lung condition? (select only one answer)

On Scale of 0 - 5 (0 the least) - Do you sleep well? (select only one answer)

On Scale of 0 - 5 (0 the least) - Do you have lots of energy? (select only one answer)

Your TOTAL score:Please add all your above scores together

Vaccinations

Pneumococcal (pneumonia) vaccinationhttps://www.nhs.uk/conditions/vaccinations/when-is-pneumococcal-vaccine-needed/

Have you booked your FLU vaccination?Please note that the surgery orders large amount of FLU vaccinations for our patients. If all our eligible patients have vaccination with the surgery this enables us not waste of NHS money by not distributing them out but also helps us reinvest income from the FLU vaccinations to extend services provided at the surgery. However please note that it still remains patient's choice where you choose to have your vaccination.

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This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Phoenix Family Care (GP Surgery in Coventry) • 103 Leamington Road, Coventry, CV3 6GQ .

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