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

We will NOT pass these contact details onto any other organisation

Section 1 (b)

Do you smoke?

*Do you smoke?

Would you like support to stop smoking?

Would you like support to stop smoking?

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

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

Would you like to talk to someone about your alcohol consumption?

*Would you like to talk to someone about your alcohol consumption?

Move to section: 1 | 2 | 3 | 4 | 5

 

Section 2

Move to section: 1 | 2 | 3 | 4 | 5

 

Section 3

Does your asthma stop you from exercising?

Does your asthma stop you from exercising?

Inhaler technique video

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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

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

5 - My chest is full of phlegm (mucus)

0 - My chest does not feel tight at all

5 - My chest feels very tight

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

0 - I am not limited doing any activities at home

5 - I am very limited doing activities at home

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

0 - I sleep soundly

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

0 - I have lots of energy

5 - I have no energy at all

Have you attended / been referred for pulmonary rehabilitation course?

Have you attended / been referred for pulmonary rehabilitation course?

Move to section: 1 | 2 | 3 | 4 | 5

 

Section 5

Do you regularly see a dentist?

Do you regularly see a dentist?

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

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

Have you experienced a hypoglycaemic attack in the last year?

Have you experienced a hypoglycaemic attack in the last year?

Are you thinking of becoming pregnant?

Are you thinking of becoming pregnant?

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

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

Are you driving?

Are you driving?

Move to section: 1 | 2 | 3 | 4 | 5

 

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