COPD Assessment

  • Please complete this form to help your nurse to assist you with reviewing your COPD. The answers provided will be used to help your nurse to give you the best advice on how to manage your symptoms and provide you with the best course of treatment for your COPD.
  • Date Format: MM slash DD slash YYYY


  • On a score of 1-5, please slide to the number that best describes your current situation as stated in the questions below. Please only select one response for each question.
  • This field is for validation purposes and should be left unchanged.