Remote Annual Respiratory Review

If you have been asked to do so by the practice, please fill in this form.

Remote Annual Respiratory Review

Remote Annual Respiratory Review

Section

Do you have COPD? *

COPD

As part of the MRC scale, please tick one of the below options to rate your breathlessness: *

COPD Assessment Test

Please select a score of 0 to 5 to help assess the severity of your symptoms:
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 completely 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 and 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 at all doing 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 confident at all leaving my home because of my lung condition
0 = I sleep soundly despite my lung condition, 5 = I don’t sleep soundly because of my lung condition
0 = I have lots of energy, 5 = I have no energy at all

The Pulmonary Rehabilitation Programme can be offered virtually to patients at present to help with managing all COPD/lung related symptoms and is run by the specialist rehabilitation respiratory team. Please see link here for more information: www.norfolkcommunityhealthandcare.nhs.uk/pulmonary-rehabilitation

Do you wish to be referred for a Pulmonary Rehabilitation Programme?

COPD Review

Cough – please select the best description of your cough from the options below:
Nocturnal cough – please select the best description of your symptoms at night:
Peripheral oedema – please select any symptoms of swelling (oedema) that apply to you:
Inhaler technique – please select the best description of your inhaler use:
Rescue medication – do you have a supply of rescue medication?
Are you on home oxygen therapy?

Health and Lifestyle

Alcohol Review

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking Review

Do you smoke? *
Do you use an e-cigarette? *
Would you like help to quit smoking? *

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what's right for you. For more information visit the Smokefree website.

BMI

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Do you have asthma? *
Please select your age category: *

Asthma

Since your last review, have you needed to see a Doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?

Adult Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?
How would you rate your asthma control during the past 4 weeks? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

If your score is 25+:

Well done

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Have you watched and understood the video(s)? *
How would you rate your inhaler technique? *
Would you like further explanation from a practice nurse?
For more help with your inhaler technique, you can visit the Asthma UK website.

In the last month...

How often does your asthma cause symptoms at night? *
How often does your asthma cause symptoms during the day? *
How often does asthma limit your activities?

Child Asthma Control Test

Let your child answer the first four questions. If your child needs help reading or understanding the question, you may help, but let your child choose select the response.

Complete the remaining three questions on your own without letting your child's response influence your answers. There are no right or wrong answers.

To be answered by the child:

How is your asthma today? *
How much of a problem is your asthma when you run, exercise or play sports? *
Do you cough because of your asthma? *
Do you wake up during the night because of your asthma? *

To be completed by the parent/guardian/carer:

During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *
During the last 4 weeks, how many days did your child wheeze during the day because of asthma? *
During the last 4 weeks, how many days did your child wake up during the night because of asthma? *

If your score is less than 12:

Very Poorly Controlled Asthma

Your child's asthma may be very poorly controlled.

Once you have submitted your form your Doctor or Nurse may recommend an asthma treatment plan to help improve your child’s asthma control.

If your score is between 13 and 19:

Poorly Controlled Asthma

Your child's asthma may not be as controlled as it should be.

Once you have submitted this form your Doctor or Nurse may suggest putting an asthma action plan in place.

If your score is 20+:

Well Controlled Asthma

Your child's asthma currently appears to be under control.

Please submit this form to update the surgery with your child's results.

The Nurse may not need to see your child this time but if they start to experience symptoms please let us know.

Does your child live with a smoker? *
Please select the types of inhalers that your child uses:

Please watch these short video(s) on how to use your inhalers

Have you watched and understood the video(s)? *
You can visit www.asthma.org.uk for help with your child's inhaler technique. How would you rate their technique? *
Would you like further explanation from a practice nurse regarding your child's inhaler technique?

In the last month...

How often does your child's asthma cause them symptoms at night? *
How often does your child's asthma cause them symptoms during the day? *
How often does asthma limit your your child's activities?
Since your child's last review, have they needed to see a Doctor or Nurse as an emergency or attended the A&E department at the hospital because of asthma?
*