COPD Review CDM COPD Review Please complete this form so that we can review your COPD (Chronic Obstructive Pulmonary Disease). Chronic = it’s a long term conditionObstructive = your airways are narrowedPulmonary = it affects your lungsDisease = it’s a medical condition We would highly recommend reading the Lung UK website. It is full of helpful information telling you about your COPD and how to better manage it. On submission of this form: We will contact you for a review if your COPD control is poor or you have indicated you would like to speak to a clinician. We will continue your current treatment if your control is good and you have indicated that you would not like to speak to a clinician. This review works well on mobile but it is easier on a computer. Tick here if you would like to email yourself this review to complete on computer. (Instant) Your Email * Your Details Patient Name * Date of Birth * Mobile number to contact you * Email (If you’d like a copy of your review) Smoking Smoking significantly worsens COPD and is usually the root cause. Do you smoke? * Yes – Please consider the stop smoking information below No Stopping smoking is the single most important thing you can do to improve your COPD and to feel better. Here is some helpful information on stopping smoking. It includes how to access specialist clinics that can support you and prescribe medication to help you stop. Stop smoking – “QUIT YOUR WAY SCOTLAND” How have you been? Some Questions How many COPD exacerbations have you had in the past year requiring steroid tablet treatment? * None 1 2 3 4 or more Repeated courses of steroid tablets puts you at risk of Osteoporosis. Would you like to discuss additional medication to help prevent this? * No thank you. I’m already on this treatment (calcium or alendronate) Yes. Please consider me for OSTEOPOROSIS PREVENTION How many times have you been admitted to hospital for COPD in the last year? * None 1 2 3 or more When do you get breathless? (MRC scale) * I only get breathless with strenuous exercise (Grade 0) I get short of breath when hurrying on level ground or walking up a slight hill (Grade 1) On level ground, I walk slower than people of my age because of breathlessness (Grade 2) I have to stop for breath when walking at my own pace on the level (Grade 2) I stop for breath after walking about 100 yards or after a few minutes on level ground (Grade 3) I am too breathless to leave the house or I am breathless when dressing/undressing (Grade 4) Inhalers and Inhaler Technique How often do you use your RELIEVER? (blue inhaler) * Less than once a day Once a day Twice a day Three times daily Four or more times daily If you have one, how often do you use your PREVENTER? (regular daily inhaler)) * Don’t have one One puff daily Two puffs daily One puff twice daily Two puffs twice daily Inhaler technique is VERY important. Taking an inhaler is not like taking a pill. An inhaler will only work well if it’s taken well. Poor inhaler technique means the medicine doesn’t get to where it’s needed and can lead to your asthma giving you lots of symptoms. Which inhaler device types do you use? Clicking will reveal a video helping your technique. * logo acf-forms activecampaign authorize aweber bootstrap campaignmonitor constant_contact getresponse googlesheets highrise hubspot mailchimp mailpoet paypal icon polylang salesforce salesforcealt stripe stripealt twilio woocommerce Zapier required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowup8 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label building icontact sendinblue sendy wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Preview MDI Ellipta Easibreathe Easyhaler Turbohaler Accuhaler Respimat NEXThaler Aerochamber Volumatic Would you like to go over your inhaler technique with a clinician? * YES, I WOULD LIKE TO GO OVER MY TECHNIQUE No thanks. I am happy with my technique Would you like a SPACER device? (see above) This can help if you are struggling to take your MDI inhaler properly. * YES, PLEASE GIVE ME A SPACER No thanks. COPD Exacerbation Plan Even people with well controlled COPD will occasionally have an episode of worsening symptoms (also called an exacerbation). It is important that everyone with COPD has an plan so that you know what to do if you have an exacerbation. CLICK HERE to get the Lothian NHS COPD plan. Would you like to have a ‘rescue pack’ of steroid and antibiotic tablets for exacerbations? * YES. Please provide me with a ‘RESCUE PACK’ No thanks Would you like to discuss an COPD plan with a clinician? * YES. I would like to DISCUSS A COPD PLAN No thanks, I already have a plan that I am happy with Pulmonary rehabilitation (PR) is a treatment programme that can help you stay active if you have a lung condition. You’ll do physical exercises and get advice from professionals about managing your condition. You will also get taught breathing techniques to help manage breathlessness. Would you like referred for Pulmonary Rehabilitation? * Yes. Please REFER ME for PULMONARY REHABILITATION No thanks You have reached the end of your COPD eReview. How would you like to proceed? * I am happy with my COPD. Please continue my current prescriptions for the next year. I would like a COPD review by TELEPHONE I would like a COPD review FACE TO FACE in the practice Any final comments on your COPD? 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. Consent * I agree to the privacy policy © 2022 Kristian Turnbull Submit If you are human, leave this field blank.