Ardblair Medical Practice > Forms > Electronic Reviews > COPD Assessment Test

COPD Assessment Test

COPD Assessment Test
Please use format day/month/year e.g. 12/05/1979
This questionnaire will help you and your healthcare professional measure the impact COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your answers, and test score, can be used by you and your healthcare professional to help improve the management of your COPD and get the greatest benefit from treatment.

For each item below, select the box that best describes you currently. Read the two statements for each item, and mark where on the scale (0-5) they fit. Scores for each are added to give an overall score (out of 40).

Coughing

Select from 0 to 5 what level best describes your current condition
I never cough
I cough all the time

Phlegm

Select from 0 to 5 what level best describes your current condition
I have no phlegm (mucus) in my chest at all
My chest is completely full of phlegm (mucus)

Tight chest

Select from 0 to 5 what level best describes your current condition

My chest does not feel tight at all

My chest feels very tight

Breathlessness

Select from 0 to 5 what level best describes your current condition

When I walk up a hill or one flight of stairs I am not breathless

When I walk up a hill or one flight of stairs I am very breathless

Activities at home

Select from 0 to 5 what level best describes your current condition
I am not limited doing any activities at home

I am very limited doing activities at home

Leaving home

Select from 0 to 5 what level best describes your current condition

I am confident leaving my home despite my lung condition

I am not at all confident leaving my home because of my lung condition

Sleeping

Select from 0 to 5 what level best describes your current condition

I sleep soundly

I don’t sleep soundly because of my lung condition

Energy levels

Select from 0 to 5 what level best describes your current condition

I have lots of energy

I have no energy at all

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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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