COPD Review - Howe of Fife Medical Practice LLP

Howe of Fife COPD Review Form

If you have been advised by the surgery to submit a COPD review please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Breathlessness Review

How often do you usually cough? *

Do you produce sputum (phlegm) when you cough? *

What colour is your sputum? *

How often do you feel short of breath? *

Do you use your inhalers regularly? *

Yes No

Do you smoke cigarettes? *

Yes No

Is there anything which has not been covered by this questionnaire that you would like to discuss with one of our clinicians? *

Yes No

When did you last have antibiotics or steroids to treat your COPD? *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 26 June 2025
Page created: 26 June 2025

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Howe of Fife COPD Review Form

Howe of Fife COPD Review Form

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