COPD review

Section

MRC Grade

Please specify: *

Short of breath only on strenuous exercise

Short of breath when hurrying or walking up a slight hill

Walks slower than contemporaries on level as breathless or stops if walking at own pace

Stops for breath after walking 100 yards on level ground or after a few minutes

Breathless if dressing or too breathless to leave the house

Assessment

Coughing

Phlegm

Tightness

Stairs

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless)

Activities

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home)

Leaving

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition)

Sleep

Energy

Total Score

This is automatically calculated and will be sent to the practice upon submission.

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