Axbridge Surgery: Houlgate Way, Axbridge, BS26 2BJ
‍Wedmore Surgery: St. Medard Road, Wedmore, BS28 4AN

Axbridge Surgery Tel: 01934 732 464
Wedmore Surgery Tel: 01934 712 774

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LONG TERM CONDITIONS QUESTIONNAIRE

Please answer all of section 1 and any other sections advised by the Practice. Required questions are marked with *

Section 1 (a) - Personal Details

*Name: *Date of Birth: *Address: *Postcode: Daytime Telephone Number: *Mobile Telephone Number: *Email Address: Name of Next of Kin: Relationship to Patient: Telephone Number of Next of Kin:

We will NOT pass these contact details onto any other organisation

Section 1 (b)

Do you smoke?

*Do you smoke?

Yes

If yes, how many a day?

How long have you smoked for?

Would you like support to stop smoking?

Yes

If you do not currently smoke, have you ever smoked?

Yes

If yes how long ago did you stop?

*Exercise – how many times a week do you take 30 mins of exercise?

*On a scale of 1-10, where 1 is not healthy and 10 is very healthy, how would you rate your diet?

*What is your current weight?

*What is your current height?

*How many units of alcohol do you drink in a typical week?

*On a scale of 1-10 where 10 means that you have no concerns, how would you rate your emotional wellbeing?

*What is your occupation? *What are your hobbies?

If you have any other issues regarding your condition that you wish to flag please contact our Reception Team who will signpost you accordingly.

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Section 2

Blood Pressure (BP): Pulse:

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Section 3

1. During the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? 2. During the past 4 weeks, how often have you had shortness of breath? 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5. How would you rate your asthma control during the past 4 weeks?

6. Does your asthma stop you from exercising?

Yes

Inhaler technique video

7. Best Peak Flow reading

How to perform your peak flow

8. Please list which inhalers you are currently using, include how many puffs you take of each one and what time of day you take each one (e.g. AM, PM, As Required):

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Section 4

This questionnaire will help your healthcare professional to measure the impact that COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your answers and test score can be used by your healthcare professional to help improve the management of your COPD and gain the greatest benefit from the treatment.

For each of the 8 questions below enter between 0 and 5:

0 - I never cough

5 - I cough all the time

Score:

0 - I have no phlegm (mucus) in my chest at all

5 - My chest is full of phlegm (mucus)

Score:

0 - My chest does not feel tight at all

5 - My chest feels very tight

Score:

0 - When I walk up a hill or one flight of stairs I am not breathless

5 - When I walk up a hill or one flight of stairs I am very breathless

Score:

0 - I am not limited doing any activities at home

5 - I am very limited doing activities at home

Score:

0 - I am confident leaving my home despite my lung condition

5 - I am not at all confident leaving my home because of my lung condition

Score:

0 - I sleep soundly

5 - I don't sleep soundly because of my lung condition

Score:

0 - I have lots of energy

5 - I have no energy at all

Score:

When do you get out of breath In the last year how many exacerbations of COPD or chest infections have you had?

Have you attended / been referred for pulmonary rehabilitation course?

Yes

Oxygen level using pulse oximeter

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Section 5

Blood Pressure (BP): Pulse:

Do you regularly see a dentist?

Yes

Have you attended an appointment in the last year for retinal screening?

Yes

Have you experienced a hypoglycaemic attack in the last year?

Yes

If yes, when was your last hypoglycaemic attack?

How often do you suffer with hypoglycaemic attacks?

Are you thinking of becoming pregnant?

Yes

Do you have any problems with sexual intercourse or erectile dysfunction that you would like to discuss?

Yes

Are you driving?

Yes

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LONG TERM CONDITIONS QUESTIONNAIRE

Section 1 (a) - Personal Details

Section 1 (b)

Section 2

Section 3

Section 4

Section 5

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