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Home > Prescriptions: COPD Review & Medication Review

Prescriptions: COPD Review & Medication Review

It is really useful to have regular information regarding your COPD (Chronic obstructive Pulmonary Disease) symptoms, even if they are well controlled. Please complete this quick form to update us with your current symptoms. If your symptoms are currently deteriorating or you are having any concerns please make an appointment with our Nurse instead by calling reception.

COPD Information Page

Calculate your CAT Score (compulsory)

Inhaler Technique

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. On receipt of this form we will review your responses and get in touch if we feel further input is required. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Prescriptions: COPD Review & Medication Review

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably mobile):

I would like to request a review via text for on online COPD review

What is your current smoking status?

How many units of alcohol do you consume per week?

What is your current weight? (In Kg or Stones)

I confirm I am happy to be contacted by the surgery (text or call) on the mobile number provided if deemed necessary

Medication Review

Do you have any concerns or side effects from your medication?

If yes - Please explain what side effects or issues you have experienced

Do you know when and how to take your medication?

Please record your most recent home/hospital/pharmacy blood pressure:

Are you on any antidepressant medication?

If you are on antidepressants, can you please select the option which best applies to you?If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

Are you happy for the doctor to update your medication review date now?

COPD Review

How often do you suffer with a cough?

Do you have a cough and if so when in the day is it worse?

No cough

Dry cough

Productive cough (brings up phelgm)

Morning

Daytime

Evening

Constant

Medication Review.

If you are bringing up phlegm what colour is it?Ignore question if your cough is dry

MRC score: Select the option below which most applied to you.

1 – Not troubled by breathless except on strenuous exercise

2 – Short of breath when hurrying on a level or when walking up a slight hill

3 – Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace

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

5 – Too breathless to leave the house, or breathless when dressing/undressing

Please calculate your CAT score using the link at the top of the form. Once calculated please document it here

Are you happy with your inhaler technique?Please watch the online videos via the link at the top of the form.

Do you use a spacer?

How many occasions have you had to use antibiotics this year for your COPD?

How many times have you been admitted to hospital due to your COPD this year?

Would you be interested in accessing pulmonary rehabilitation? For more information: https://www.england.nhs.uk/ourwork/clinical-policy/respiratory-disease/pulmonary-rehabilitation/

Do you have a spare rescue pack (antibiotics & steroids)?

I confirm that the information provided is accurate to the best of my knowledge

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 Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

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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