COPD REVIEW PRE-APPOINTMENT QUESTIONNAIRE

Please only complete if requested to do so by Mackenzie Medical Centre before your COPD review appointment.

Your Details

Name *

Date of Birth *

Phone Number *

COPD Review

CAT Questions

MRC Scale

Please choose one option that indicates your degree of breathlessness related to activities. *

0 - I only get breathless with strenuous exercise

1 - I get short of breath when hurrying on the level on walking up a slight hill

2 - I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level

3 - I stop for breath after walking about 100m or after a few minutes on the level

4 - I am too breathless to leave the house or I am breathless when dressing or undressing

Consent

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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COPD REVIEW PRE-APPOINTMENT QUESTIONNAIRE

COPD REVIEW PRE-APPOINTMENT QUESTIONNAIRE

Further Information