COPD Assessment Form Step 1 of 2 50% First Name* Last Name* Email* Date MM slash DD slash YYYY Have you had a physician office visit for your COPD at least once in the last 6 months? Yes No Do you use Oxygen therapy? Yes No If yes, how often and how many (LPM) Liters Per Minute? Do you have shortness of breath during activities or exercise? Yes No How many times do you have chest tightness, cough, shortness of breath or wheezing? None 2 or less times a week More than 2 times a week, but less than 1 time a day Daily More than 1 time a day How often does your doctor check your lung function by spirometry testing? Annuallly At least every other year Only when I was diagnosed Never Date of last spirometry test? MM slash DD slash YYYY Result of last spirometry testNormalAbnormalHave you gained or lost any weight? Yes No Have you had any changes in your smoking status? Yes No Do you monitor your blood pressure as prescribed by your physician? Yes No No MD order Last BP reading Have you had any changes in your COPD medications? Yes No If yes, please list changesHave you achieved your current COPD goal? Yes No What goal do you want to achieve for your COPD before your next follow-up?** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness! EmailThis field is for validation purposes and should be left unchanged. Δ
