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.

Consent *

I consent

Patient Information

First Name *

First

Last Name *

Last

Mailing Address *

Mailing Address

Mailing Address

Mailing Address

City

City

Province

Province

Postal Code

Postal Code

Group/Policy#

Client ID#

Date of Birth (DD/MM/YYYY) *

Gender *

Male

Female

Telephone # *

Email Address *

Preferred Method of Contact *

E-mail

Telephone

What is your preferred pharmacy location? *

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

Demographics

Occupation *

Clerical

Homemaker

Sales

Skilled Labour

Professional/Manager

Student

Retired

Unemployed

Other Labour

Disabled

OtherOther

Education *

Some High School

High School Diploma

Some College or University

University or College Degree

Race/Ethnicity *

White (Caucasian)

Aboriginal

Black (Afro-Caribbean)

East Asian (Chinese, Vietnamese, Filipino, Korean, etc.)

South Asian (East Indian, Pakistani, Sri Lankan, etc.)

Other non-white (Latin American, Arab, West Asian)

History

Have you ever been diagnosed, ever been told, or have you had problems with the following? *

High Blood Pressure

High Cholesterol

Kidney/Bladder Problems

Circulation Problems

Heart Disease/Chest Pain

Thyroid Disease

Diabetes

Arthritis

Depression or Anxiety

Drug Allergies

Stroke

Problems with sexual function

Numbness/Pain/Tingling in hands or feet

Eye/Vision Problems

Frequent Nausea/Constipation

OtherOther

Check all that apply

What is your height? * 4' 8" 4' 9" 4' 10" 4' 11" 4' 12" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 5' 12" 6' 0" 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11" 6' 12"

(If your height falls in between, please round up)

What is your current weight in lbs.? *

example: 175 lb.

In the past year, has your weight changed? *

Lost more than 10 lbs.

Gained more than 10 lbs.

Stayed about the same

When were you diagnosed with COPD? *

Have you received COPD education? *

Yes

No

If yes, when?

Do you have any physical limitation that may affect your ability to perform your self-care? *

Hearing Problems

Problems with use of hands

Vision Loss (not corrected by glasses)

No physical limitation

Check all that apply

Do you Smoke? *

Yes

No

If yes, how much do you smoke?

Are you exposed to second hand smoke in the home? *

Yes

No

How do you learn best? *

Listening

Watching

Hands on/Doing

Check all that apply

Have you had any emergency room visits or 911 calls related to COPD in the last 3 months? *

Yes

No

If yes, number of visits in the last 3 months?

Have you had any hosptial admissions due to COPD? *

Yes

No

If yes, number of admissions in the last 3 months?

Have you missed any days of work, school or usual routine because of COPD within the last 30 days? *

Yes

No

If yes, number of days missed in the last 30 days?

Have you received a seasonal flu vaccine? *

Yes

No

If yes, when?

Have you received a Pneumovax vaccine? *

Yes

No

Unsure

If yes, when?

Do you have a support person at home? *

Yes

No

Breathlessness Scale

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

Breathlessness Scale, choose the statement that best describes your degree of breathlessness related to activities. *

Not troubled by breathlessness except on strenuous exercise

Short of breath when hurrying or walking up a slight hill

Walks slower than peers on level ground due to dyspnea, or must stop for breath when walking at own pace

Stops for breath after walking about 100m or after a few minutes on level ground

Too breathless to leave the house, or breathless when dressing or undressing

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.

Do you take/use COPD medications? *

No

Pills

Inhalers

OtherOther

check all that apply

Do you take any nutritional supplements? *

No

Vitamins

Herbal Supplements

Other

check all that apply

Sometimes it can be hard to remember to take medications. During the last 7 days, how many days have you missed taking your COPD medication?

0

1

2

3

4

5

6

7

How important is it to you to take your medications?

0

1

2

3

4

5

6

7

8

9

10

0 = Not Important, 10 = Very Important

How sure are you that you can take your medications?

0

1

2

3

4

5

6

7

8

9

10

0 = Not Sure, 10 = Very Sure

Goal Setting

Having COPD means you may need to make changes. What changes, if any, would you like to make now? *

Learn more about COPD

Medication taking

Correct Inhaler Technique

Avoiding weight loss/nutrition

Quit smoking

Breathing Techniques

OtherOther

Do you have any cultural factors that may make it more diffcult for you to control your COPD? *

Yes

No

If yes, please explain

Workplace Productivity and Impairment Score

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

Are you currently employed (working for pay)? *

Yes

No

During the past seven days, how many hours did you miss from work because of problems associated with your COPD?

(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.)

During the past seven days, how many hours did you miss from work because of any other reason such as vacation, or holidays?

(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)

During the past seven days, how much did your COPD affect your productivity while you were working?

0

1

2

3

4

5

6

7

8

9

10

0 = COPD had no effect on my work, 10 = COPD completely prevented me from working

During the past seven days, how many hours did you actually work?

(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)

During the past seven days, how much did your COPD affect your ability to do your regular daily activities, other than work at a job (By regular activities, we mean shoppings, exercising, studying, etc.)

0

1

2

3

4

5

6

7

8

9

10

0 = COPD has no effect on my daily activities, 10 = COPD completely prevented me from doing my daily activities

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