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).
My chest does not feel tight at all
My chest feels very tight
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
I am very limited doing activities at home
I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition
I sleep soundly
I don’t sleep soundly because of my lung condition
I have lots of energy
I have no energy at all
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.