COPD

Many thanks for taking the time to complete this form about your COPD.

The information that you provide on this form will be passed to a clinician, who will review your responses and get in touch with you if there are issues that require follow up.

For each item below, select the closest option that best describes your current situation. For example, if you cough for about half the days of the week you might select 3 for the first question.

COPD

Name

Date of birth

Cough

Mucus

Tight chest

Breathless

Activities

Leaving house

Sleep

Energy

Smoking statusDo you smoke (cigarettes, cigars and vaping). If yes, then how many a day. If you quit, tell us how many you used to smoke and when you quit.

AlcoholAlcohol units per week

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Portland Medical Practice • Anchor Meadow, Aldridge, Walsall, West Midlands, WS9 8AJ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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