How is your COPD?

DD slash MM slash YYYY
How often do you cough?
Select a number 0-5. 0 being never cough, 5 being i cough all the time
Do you have phlegm (mucus)?
Select a number 0-5. 0 being I have no phlegm, 5 being my chest is completely full of phlegm
Does your chest feel tight?
Select a number 0-5. 0 being my chest does not feel tight at all, 5 being my chest feels very tight
How breathless are you when you walk up a flight of stairs or a hill?
Select a number 0-5. 0 being I am not breathless, 5 being I am very breathless
Is your activity at home limited?
Select a number 0-5. 0 being not limited at all, 5 being very limited at home
How confident are you when you leave home?
Select a number 0-5. 0 being I am confident when leaving home, 5 being I am not at all confident when leaving home
How do you sleep?
How much energy do you have?
Please describe your breathlessness
This field is for validation purposes and should be left unchanged.

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