RESPIRATORY ASSESSMENT

Personal Details

First Name Surname Date of Birth Contact Telephone Number Email Address

Score each of the 8 questions below between 0 and 5:

0 - I never cough

5 - I cough all the time

Score:

0 - I have no phlegm (mucus) in my chest at all

5 - My chest is full of phlegm (mucus)

Score:

0 - My chest does not feel tight at all

5 - My chest feels very tight

Score:

0 - When I walk up a hill or one flight of stairs I am not breathless

5 - When I walk up a hill or one flight of stairs I am very breathless

Score:

0 - I am not limited doing any activities at home

5 - I am very limited doing activities at home

Score:

0 - I am confident leaving my home despite my lung condition

5 - I am not at all confident leaving my home because of my lung condition

Score:

0 - I sleep soundly

5 - I don't sleep soundly because of my lung condition

Score:

0 - I have lots of energy

5 - I have no energy at all

Score:

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