Welcome to the Breathing Better with COPD - Initial Patient Self-Assessment.  This questionnaire will take approximately 15 minutes to complete.  You will need to complete this questionnaire in a single session as it can not be saved and completed later.  By completing this questionnaire your pharmacist will be able to better understand your COPD to better inform you or recommend changes that will benefit you in managing your COPD.   Your responses are strictly confidential and will only be used by the pharmacist providing asthma consultations with you.

Once the questionnaire is finished please click submit.  A copy of the questions and your responses will be e-mailed to you.
*a red asterisk indicates a response is required
COPD Patient Self Assessment

Patient Consent

The information collected as part of this online self-assessment questionnaire contains confidential personal health information; therefore it is important for you to understand the privacy and security issues involved. All of your personal health information will be stored using state of the art secure technology to ensure security and confidentiality. Your employer will not receive any personal health information that will identify you as an individual. The pharmacist providing Chronic Disease Management Services will only receive a copy of your results to discuss with you during your consultation and MHCSI will use non-identifying data combined with others in a large statistical database for aggregate reporting only.

By clicking below, you are agreeing to the above statements and release your information to be used only as specified above.

Patient Information

First
Last
(example: Lawtons Drugs Main Street, Dartmouth; Sobeys Pharmacy Mumford Road, Halifax)

Demographics

History

Check all that apply
(If your height falls in between, please round up)
example: 175 lb.
Check all that apply
Check all that apply

Breathlessness Scale

Choose the statement that best describes your degree of breathlessness related to activities.

Taking Medication - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Taking medication means that you take medicines that have been prescribed by your Healthcare Provider to treat your COPD and other health conditions. These may be pills, inhaled products, creams, or other medicines that you inject. For the next several questions, please answer for all the medicines that you take.

check all that apply
check all that apply
0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Goal Setting

Workplace Productivity and Impairment Score

The following questions ask about the effect of your COPD on your ability to work and perform regular activities.

(Include hours you missed on sick days, times you went in late, left early, etc., because of your asthma. Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
0 = COPD had no effect on my work, 10 = COPD completely prevented me from working
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
0 = COPD has no effect on my daily activities, 10 = COPD completely prevented me from doing my daily activities
Sending