COPD Assessment

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COPD Assessment

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Patient Details

Title

First Name

Surname

Date of BirthDD/MM/YYYY

Address

Post Code

Contact Information

Contact Telephone Number

Name of the contact

Review Questions

Rate the following based on the response that best describes you currently

Your cough

Phlegm (mucus)

Tightness of chest

Breathlessness when walking up a hill or one flight of stairs

Doing any activities at home

Confidence with leaving your home

Your sleep

Energy levels

I confirm that to the best of my knowledge the information provided in this form is correct

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Key Information

BBC Health News

COPD Assessment

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